maxillary antrum Flashcards
3 main fcts of paranasal sinuses
resonance to voice
reserve chamber for warming inspired air
reduce weight of skull
embryology
form during 3rd and 4th foetal months
- evaginations of mucosa in nasal cavity
maxillary and ethmoid fairly large at birth
sphenoid and frontal - expansion during first few yrs of life
opening - ostium
middle meatus (hiatus semilunaris)
opening approx 4mm diameter
located superiorly on medial wall of sinus
- position can predispose to sinusitis - hard to drain
lined with mucosa
can become narrowed/blocked during episodes of inflammation/disease
differential diagnoses
dental sinus TMD tumours MS atypical facial pain
clinical significance
OAC/OAF root in antrum sinusitis benign lesions malignant lesions
when should you suspect a malignant lesion?
when you can’t see walls of sinus
which sinus is usually the largest?
MS
shape of MS
pyramid
dimensions of MS
av volumetric space 15ml in adult
37mm high
27mm wide
35mm AP
what are generally found on the posterior wall of the sinus cavity and what is the clinical significance of this?
alveolar canals that transport the posterior superior alveolar vessels and nerves to the maxillary posterior teeth
can get referred pain e.g. pts think they have toothache
MS and roots of molars and sometimes premolars
may project into the floor
roots may perforate the bone so that only the mucosal lining of the sinus covers them
if PA pathology could inflame the mucosa - can get mucosal thickening
MS lining
pseudostratified ciliated columnar epithelium
cilia mobilise trapped particulate matter and foreign material within the sinus and move it towards the ostia for elimination into the nasal cavity
diagnosis of OAC/OAF
size of tooth
radiographic position of roots in relation to antrum
bone at trifurcation of roots
bubbling of blood
nose holding test (careful as can create an OAC)
direct vision
good light and suction (echo)
blunt probe (careful as can create an OAC)
OAC pre-op assessment purpose
so you can warn pt - explain it is a 2D image so roots may not be as close but there is a risk
management of acute OAC if small or sinus lining intact
inform pt
encourage clot
suture margins
small OACs <2mm usually heal with normal blood clot formation and routine mucosal healing
management of acute OAC if large or lining torn
close - if you can get primary closure not under tension without a flap then do it
BAF
- 3-sided - straight or slightly splayed for wider base
- need to release periosteum (fibrous, inelastic)
- paint line with scalpel where relieving incisions end
- once you have released it the flap becomes v elastic
so can cover socket w no tension
- non-resorbable (prolene)
- combination of sutures to keep it closed (mattress
sutures evert edges so get better healing as mucosa
not interrrupted
acute OAC antibiotics
perforation introduces oral bacteria
use prophylactic antibiotics
7 days
amoxicillin or doxycycline
acute OAC POIs
review appt in a couple of days don't forcibly blow nose or stifle a sneeze (by pinching nose) - sneeze with mouth open steam/menthol inhalation to keep sinuses clear avoid using straw no smoking don't prod area no vigorous mouthwashing no wind instruments
chronic OAF - pts may complain of
problems with fluid consumption (fluids from nose)
problems with speech/singing (nasal quality)
problems playing brass/wind instruments
problems smoking cigarettes/using straw
bad taste/odour/halitosis/pus discharge
- may need to squeeze/run blunt probe over
pain/sinusitis type symptoms
management of chronic OAF
may need CBCT
excise sinus tract/fistula
- if just close over it will reform
- cut round it up to sinus then pull tube out, excavator for
remnants
antral wash out - remove all of the soft GT
BAF
buccal fat pad with BAF
palatal rotational flap
bone graft/collagen membrane
(tongue flap - historical)palatal rotational flap for chronic OAF
cut finger like projection of thick mucosa
leave attached and turn over the OAF
leaves raw bit on palate
- can make an acrylic healing plate to protect it while it heals
fracture of maxillary tuberosity - aetiology
single standing molar (unsupported bone) unknown UE molar/8 pathological gemination/concrescence extraction in wrong order - create a last standing molar inadequate alveolar support - have finger and thumb either side at all times - if needing too much force stop and do surgical
fracture of maxillary tuberosity - diagnosis
noise
movement noted both visually or with supporting fingers
>1 tooth movement
tear on palate - sharp bone edges
fracture of maxillary tuberosity - management options
dissect out and close wound
reduce and stabilise
fracture of maxillary tuberosity - dissect out and close wound
if small
don’t just pull as you will rip
may need a BAF
fracture of maxillary tuberosity - reduce and stabilise
if large or have other teeth attached that you don’t want to extract
reduction
- fingers (gauze) or gently w forceps
- may need to disimpact it first
fixation
- needs to be rigid to get bony healing - if flexible splint
will get fibrous healing (CT)
- the more teeth you include the more rigid it will be (as
you can only splint anteriorly)
- ortho buccal arch wire spot-welded with composite (if
can’t get moisture control can use GI but harder to
remove
- (arch bar) - hard to get in and out and bad for PD health
- splints - can get lab to make emergency splint - but
need pt numb to take imp and cover area in vaseline
so don’t rip it out
see pt in a couple of days to check splint
fracture of maxillary tuberosity - remember to:
remove or tx pulp ensure occlusion free - reduce tooth to be extracted or soft splint to relieve ABs remove tooth 8wks later (SR) review next day
fracture of maxillary tuberosity - POIs
antiseptics - cotton bud and CHX round splint
soft diet
painkillers
baby toothbrush from next day
root or tooth in MS - management
check not in suction/floor/on pt etc
confirm radiographically by OPT, occ, PA (+/- CBCT)
decision on retrieval
- if can see/easy to get
- risk pushing it further
if in doubt or retrieval difficult - refer
rarely may be tucked under intact mucosa, so not in sinus
root or tooth in MS - retrival
OAF type approach/through socket
- flap design
- good light
- open fenestration with care - may need bone nibblers and electric bur
- suction - efficient and narrow bore
- small curettes (discoid)
- irrigation
- ribbon gauze - soak it and gently pack into socket then pull it out and sometimes root comes out
- close as for OAC
Caldwell-luc approach
- buccal sulcus
- buccal window cut in bone
ENT
- endoscopic retrieval
- go in through ostium and widen it to get root out
sinusitis
sinus inflammation and infection
why does sinusitis often present to the dentist first?
symptoms of pain and pressure in maxillary posterior teeth
floor v close to root apices of maxillary posterior teeth
- roots freq extend into sinus cavity
sinusitis S+S
facial pain and pressure most freq congestion/fullness nasal obstruction paranasal drainage hyposmia fever headache dental pain halitosis fatigue cough (constant post-nasal drip) ear pain anaesthesia/paraesthesia over cheek
aetiology of sinusitis
most commonly ppt by the effects of a viral infection
- inflammation and oedema
- obstruction of ostia - sinus can’t empty
- stagnation and trapping of debris within sinus cavity
normal physiological fct further disrupted by the cellular damage that occurs to the mucosal lining
- affects normal ciliary fct
predisposing factors/mucociliary clearance patterns may be altered by:
- allergens
- inflammation
- anatomic abnormalities - opening smaller/in different places
when sinus can no longer evacuate its contents efficiently:
- build up of pressure
- opportune situation for bacterial overgrowth of normal flora
sinusitis - important to rule out a dental cause
PA abscess
PD infection
deep caries
recent ext socket
TMD
neuralgia or atypical facial pain/chronic midfacial pain
facial pain in absence of obvious dental aetiology requires further investigation
indicators of sinusitis and not toothache
discomfort on palpation of infraorbital region
a diffuse pain in the maxillary teeth
- can’t identify which tooth
equal sensitivity from percussion of multiple teeth in same region
pain that worsens with head or facial movements
aims of tx for sinusitis
tx presenting symptoms
reduce tissue oedema - so pt can clear their sinuses
reverse obstruction of the ostia
tx for sinusitis
decongestants reduce mucosal oedema
local measures first - humidified air - steam/menthol inhalations - go in and out so don’t burn skin
(ABs)
decongestants for sinusitis
ephedrine nasal drops 0.5%, 1 drop each nostril x3 daily when required
oxymetazoline (nasal spray)
ABs for sinusitis
only if:
- symptomatic tx is not effective/symptoms worsen/symptoms severe
- S+S point to a bacterial sinusitis - purulent discharge lasting 7 or more days, bad taste, pus drainage down back of throat
SDCEP
- phenoxymethylpenicillin 250mg, 40 tablets, 2 x4 daily
- doxycycline 100mg, 2 capsules on first day followed by 1 capsule daily for 7 days (if penicillin allergy or intolerance)
foreign object in sinus
e.g. tooth, root, fractured endo instrument if retrievable remove at once if not - inform pt - take a radiograph - document in pt notes - place pt on appropriate meds - refer to OMFS or ENT
fungal infections
v occ a non-resolving sinusitis may be due to a fungal infection
can cause expansion of the bony walls by increased mucus secretion and fungal growth - fungal hyphae grow into walls
hard to tx - sometimes need surgery
trauma and iatrogenic factors
can cause sinusitis by violating the integrity of the bony cavity and sinus membrane sinus wall fracture orbital floor fracture RCT - initiate PA inflammation at floor of sinus - introduce bacteria into sinus - file pushed into sinus tooth ext - perforation - roots/tooth displaced into sinus dental implants/sinus lifts deep PD tx nasal packing NG tubes mechanical ventilation
= a perforation into the sinus will introduce oral bacteria therefore prophylactic ABs should be used
benign lesions
polyps, papillomas, antral pseudocysts, mucoceles, retention cysts
beware as an inverted papilloma has the potential to become malignant
odontogenic cysts/tumours expanding into sinus
- but grow so may need destruction surgery
malignant lesions
primary tumours
local spread from adjacent sites
