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maxillary and paranasal sinuses Flashcards

1
Q

maxillary sinus: function

A

vocal resonance
olfactory function (smell)
warming and humidifying air
decrease the weight of the skull

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2
Q

blood supply to the maxillary sinus

A

maxillary artery
branches:
1. posterior superior alveolar artery
2. infraorbital artery
3. posterior lateral nasal artery

1 + 2: branch of pterygopalatine portion of maxillary artery
3. branch of sphenopalatine (forms terminal branch of maxillary artery)

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3
Q

where does the maxillary sinus drain into?

A

the maxillary ostium

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4
Q

pneumatisation: definition + radiographic presentation

A

‘pneumatised sinuses’

-sinus extension into particular anatomical structure
-poorly understood
-results as increase in volume of the sinus
-occurs with increasing age
-following loss of post dentition
-the sinus dips in between these teeth, there is not much bone around the apices of the two teeth: risk of perforation and forming a communication.

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5
Q

why is the maxillary sinus relevant in dentistry?

A

has a close relationship with the oral cavity

  1. pts with maxillary sinusitis may present to the dentist believing they have a toothache
  2. pts with dental pathology in the maxilla may secondarily develop odontogenic sinusitis
  3. dentists may intrude into the maxillary sinus during surgery or other dental procedures
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6
Q

relevance of the maxillary antrum

A

problems arise when:
1. exodontia: XLA
2. endodontics: thin bone around the apex, may perforate apex + force material into the sinus
3. implant placement

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7
Q

schneiderian membrane + septa???

A
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8
Q

risks with extracting upper posterior teeth

A

OAC
OAF (if OAC not managed)
displacement of teeth/roots/FB
maxillary tuberosity fracture

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9
Q

oro-antral communication: definition

A

a non-epithelialised passage between the oral cavity and the maxillary antrum, which can be as a result of exodontia

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10
Q

oro-antral fistula: definition

A

a pathological epithelial lined passage between the oral cavity and the maxillary antrum

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11
Q

oro-antral communication vs fistula

A

communication is non-epithelialised

fistula: occurs when communication is left and it epithelialises. fistula: epithelialised

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12
Q

risk factors for an OAC

A

close relationship between the tooth/root and the sinus/antrum
thin alveolar bone around the apex of the tooth
PA pathology/infection
root morphology: palatal root is much higher up and within the sinus cavity
lone standing molars: with a pneumatised sinus
traumatic/difficult extractions: too much apical pressure can push the tooth into the sinus
technique

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13
Q

oro-antral communication: signs and symptoms

A

signs:
clinically visible: can see a hole
resonant

symptoms:
-air/ liquid bubbling/ reflux into the nose
-discharge of infected material
-congestion, pain
-sinus like symptoms (sinusitis)
-air escaping into mouth

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14
Q

if the pt comes back with any symptoms of an OAC, what should you not do?

A

the valsava manoeuvre
forced expiration with a closed mouth and nose, will create an OAC

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15
Q

oro-antral fistula: signs and symptoms

A

signs:
-soft tissue proliferation around the socket (there is tissue trying to heal but doesn’t look right)
-prolapse of sinus lining
-discharge

symtoms:
air/liquid bubbling/reflux into the nose
air escaping to the mouth

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16
Q

OAC: management

A

monitor vs closure

  1. monitor if there are no symtoms: heals spontaneously. if no healing, then treat for OAF
  2. closure: 4 options for closure.
    -buccal advancement flap
    -palatal advancement flap
    -buccal fat pad
    -PRF (platelet rich fibrin) membrane closure
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17
Q

OAF: management

A

excision and histopathology. remove the fistula (chronic granulation tissue) and send it to the lab to check it is normal granulation tissue, then close hole

closure: a newly created OAF should be closed immediately
an OAF that is diagnosed later should be allowed a period of 6 weeks to close spontaneously as attempt to close fistula earlier is likely to fail as tissues are more friable during their initial healing phase.

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18
Q

buccal advancement flap:

advantages and disadvantages

A

-technique sensitive: one shot, but can be straightforward
-can be done under LA
-completely closes the fistula to facilitate healing by primary intention: heals well
-heals well but thin tissue- easy to perforate, sometimes limited mobility
-difficult to get good closure with large OAC
-lose buccal depth, height of the sulcus
-difficult to achieve a tension-free closure of a large extraction
-not as good for larger OACs

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19
Q

palatal advancement flap:

advantages and disadvantages

A

-harbours palatine vessels, good blood supply
-more tissue with less tension, little shrinkage
-thicker: more resistant to trauma + preserves sulcus depth.
-can be used when a buccal flap has failed
-palatal flap more robust + stronger than buccal but this technique is better undertaken under GA and by a specialist
-good for larger OACs

dis:
-very technique sensitive
-granulating palatal bone: leaves exposed palatal bone. it heals by granulation- buccal better healing

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20
Q

buccal fat pad

advantages and disadvantages

A

technique sensitive
often used for larger defects/ OACs in combination with other

done under GA

buccal fat pad drawn forward with buccal advancement flap to make it more robust

however removing it can lead to a defect in their face: warn the pt of this risk

21
Q

platelet rich fibrin

advantages and disadvantages

A

optimum technique
no local flap required
good healing, but requires training and kit
not freely available on NHS
maintains sulcus depth

22
Q

buccal advancement flap: technique

A
  1. make a 2 sided flap with a broadened base
  2. incise some of the palatal tissue and undermine it
  3. the buccal plate needs to be removed or reduced to eliminate sharp bone
23
Q

displaced root: where could the root have gone?

A

socket (between the lining of the periosteum of the gum and the bone of the socket)
mucoperiosteum
antrum
swallowed
inhaled
suction

24
Q

displaced roots: management

A
  1. take a PA or CBCT
  2. removal of root
  3. caldwell-luc/lateral window: if the root is within the antral air space. involves raising a buccal mucoperiosteal flap in the canine fossa region to expose the anterior wall of the antrum
  4. endoscopy: to retrieve the root
25
antral regime
a set of procedures aimed at ensuring a healthy maxillary sinus before attempting to close an oro-antral communication (OAC) or oro-antral fistula (OAF) if you take a tooth out and suspect an OAC, or a root has gone in the antrum, then manage the pt with antral regime
26
antal regime: steps
analgesia: NSAIDs best no nose blowing sneeze like a horse no straws: creates a vaccum decongestants: keeps the sinuses aerated, e.g. steam with albas oil use clinical judgement when prescribing abx: consider broad spectrum antibiotic
27
maxillary tuberosity fracture: definition
a portion of alveolar bone that has come with the tooth small fractures common in posterior maxillary molar, usually lone standing check- often not an issue check when starting to luxate/mobilise tooth: what is moving?
28
maxillary tuberosity fracture: risks
risk of OAC risk of bleeding
29
tuberosity fracture: management
if attached and small: leave and consider antral regime + review more movement than usual during XLA then STOP and consider splinting (wire and GIC/comp). refer: non-urgent significant bleeding when extracted (rare), replace the tooth and tuberosity back into the socket bite on gauze and call for advice (secondary care OS or OMFS)
30
pathology/diseases of the maxillary sinus
infection of the antrum: sinusitis mucous retention cysts odontogenic and non-odontgenic cysts genetic, metabolic and tumour-like diseases benign or malignant neoplasms
31
acute odontigenic maxillary sinusitis
unilateral different to non-odontogenic sinusitis related to their teeth- can get it from dental infection causes: -periapical infection/abscess -periodontitis -peri-implantitis -post-extraction infection -trauma -odontogenic cysts -osteomyelitis -displacement into sinus
32
chronic odontogenic sinusitis
prolonged low grade inflammation in the antral mucosa post acute phase/recurrence of acute sionusitis antral mucosa is thickened: oedema, leukocyte infiltration, sometimes formation of polyps mixed miroflora: acute: commonly viridans streptococci and anaerobes, e.g. peptostreptoccus, fusobacterium chronic: polymicrobial, viridans streptococci and anaerobes- similar to acute but yield reduced numbers of bacteria
33
acute non-odontogenic sinusitis: bacteria causing it
predominantly aerobic bacteria steptococcus pneumoniae haemophilius influenzae staphylococcus aureus
34
acute odontogenic maxillary
i
35
inflammation (sinusitis) infections
chronic maxillary sinusitis acute maxillary sinusitis mucosal cysts of the antrum
36
chronic maxillary sinusitis definition signs/symptoms
chronic inflammation of the mucosa lining the sinus often little or no systemic upset local signs and symptoms can be subtle but persistent pus or discharge are not uncommon toothache during chewing, mobility of teeth, migraine, dull headache requires symptoms to persist for 12 weeks
37
chronic maxillary sinusitis: radiological findings
opacification due to thickening of the mucosa lining the antrum which reduces the size of the air space on sinus imaging the antral mucosa is oedematous and contains a dense infiltrate of lymphocytes, plasma cells and macrophages
38
chronic maxillary sinusitis: treatment
no tx may be necessary when tx needed, promoting drainage is the usual goal of treatment because obstruction of the ostium is usually a feature
39
maxillary sinusitis: best imaging
OPT useful but CBCT more gold standard: more reliable info
40
acute maxillary sinusitis: definition signs and symptoms radiographic presentation (non-odontogenic)
occurs in association with a cold or influenza chronic sinusitis is a predisposing factor patients may interpret symptoms as a toothache and present to their dentist pain + systemic upset stiffness, nasal discharge, tenderness of the cheek and of posterior teeth on affected side dull or intense pressure like pain, erytheme, swelling of the cheek and anterior maxilla, pressure or fullness in the maxillary sinus, headache, malaise, fever, halitosis, mucopurulent rhinorrhea, nasal congestion/obstruction, general malaise and lymphadenopathy associated with accumulation of inflammatory exudate and neutrophils in the sinus, may appear as an air/fluid level on imaging. or if all air is displaced, as a totally opaque antrum
41
acute maxillary sinusitis: risk of progression to where?
orbital cellulitis (spread to the orbit) cavernous sinus thrombosis (rare) meningitis (rare) intracranial abscess (rare)
42
acute maxillary sinusitis: managment
antibiotic therapy, decongestants (ephedrine nasal drops), analgesia and inhalations are used in combination
43
diagnosis of sinusitis
exclude or confirm odontogenic cause if excluded: GP/ENT referral
44
chronic maxillary sinusitis: management
elimination of source antimicrobials
45
sinus cysts: definiton radiographic presentation
mucosal cysts in the lining mucosa of the maxillary antrum variation in normal anatomy radiographic changes: mucosal thickening if in doubt, refer for CBCT well circumscribed and asymptomatic- unlikely to be sinister remember red flags
46
red flags in radiographic reporting
loss of symmetry and apparent soft tissue masses disordered anatomy- displaced teeth bone erosions- look at the anatomical margins (intact bone disorders) teeth floating in air relevant medical history
47
sinus cysts: differential diagnoses
radicular cysts (originating from a carious maxillary tooth- odontogenic cyst) keratogenic odontogenic tumour: rare, painless expansion of maxillary fibrous dysplasia/pagets
48
neoplasia
be aware of red flag symptoms: loss of weight, loss of appetite, asymmetry, abnormal discharge nasal discharge (bleeding or other) unilateral nasal obstruction radiological features mobility of teeth ocular symptoms neurological signs (CN cranial nerve 5)

oral med/sur (6 decks)

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