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BDS4 CDS Oral Surgery > maxillary sinus > Flashcards

maxillary sinus Flashcards

1
Q

sinuses in the face

4

A

frontal sinus
sphenoid sinus
ethmoid air cells
maxillary sinus (dental most concerned)

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2
Q

embryology of sinuses

3

A

Formation occurs during 3rd and 4th foetal months, with evaginations of the mucosa of the nasal cavity

Maxillary and ethmoid relatively large at birth

Sphenoid and frontal undergo expansion within the first few years of life

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3
Q

3 functions of paranasal sinuses

A
  • resonance to the voice
  • reserve chambers for warming inspired air
  • reduce the weight of the skull
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4
Q

maxillary sinus a.k.a

A

maxillary antrum

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5
Q

maxillary sinus anatomy

and dimensions

A

Usually, the largest of the sinuses

Pyramid-shaped cavity within the body of each maxilla

Volumetric space 15ml in average adult

Average dimensions: variation between people
* 37mm high
* 27mm wide
* 35mm antero-posteriorly

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6
Q

opening of the maxillary sinus (ostium)

5 points

A

Middle meatus (hiatus semilunaris)

Opening approx. 4mm diameter

Located superiorly on medial wall of sinus (large collection of fluid/mucous before it can drain)

Lined with mucosa

Can become narrow or blocked during episodes of inflammation/disease easily

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7
Q

posterior wall of maxillary sinus has

A

alevolar canals that transport the posterior superior alveolar vessels and nerves to the maxillary posterior teeth

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8
Q

maxillary sinus and roots of maxillary teeth

A

Roots of maxillary molars and sometimes premolars may project into the floor of the maxillary sinus

The roots may perforate the bone so that only the mucosal lining of the sinus covers them

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9
Q

epithelium of sinuses

A

pseudostratified ciliated columnar epithelium (produce mucous)

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10
Q

role of cilia in epithelium of sinuses

2

A
  • mobilise trapped particulate matter and foreign material within the sinus
  • move this material towards the ostia for elimination into the nasal cavity

pseudostratified ciliated columnar epithelium

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11
Q

ostia/ostium

A

opening of sinus

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12
Q

6 possible clinical issues that can occur to msaxillary sinuses

A
  • Oro-Antral Communication (OAC) - Acute
  • Oro-Antral Fistula (OAF) - Chronic
  • Root in the antrum
  • Sinusitis
  • Benign Lesions
  • Malignant Lesions
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13
Q

most common clinical issues involving maxillary sinus

A

OAC/OAF

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14
Q

aetiology of OAC/OAF

A

Extraction of toot/RR and due to close relation of floor maxillary antrum/sinus and tooth create a communication either by breaking bone of floor or ripping the mucosa lining and oral cavity(previously wasn’t there)
* Get bacteria ingress into sinus
* Affect function of sinus

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15
Q

how to dx OAC/OAF

7 main

A
  • Size of tooth
  • Radiographic position of roots in relation to antrum predict
  • Bone at trifurcation of roots possible to come out in extraction
  • Bubbling of blood
  • Nose holding test gently - careful as can create an OAC; if just broken bone, lining can be intact and this can break it
  • Direct vision
  • Good light and suction – echo sound

Blunt probe (take care not to create an OAC) avoid

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16
Q

pre op assessment for risk OAC

3 indications from radiograph

A

close radiographic relation between roots and antrum

Loan standing upper molar has increased chance of communication and/or # tuberosity

Splayed roots increased chance

Arrow area – 26 can see maxillary sinus has been wrapped around the roots (less so on 16), very little bone – high chance communication and # tuberosity

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17
Q

OAC is

A

acute
just happened, immediate post extraction - can see bleeding, potential prolapse of lining of maxillary antrum

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18
Q

OAF is

A

chronic

communication made - management failed and opening persists - sinus tract has been created now

no bleeding

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19
Q

management of OAC

A

Inform patient

If small or sinus lining intact: majority
* Encourage clot
* Suture margins pack has risk of pushing into sinus
* Antibiotic (area of debate)
Post-op instructions most important
* Minimising pressure formation within the sinuses and mouth
* Avoid blowing nose, avoid sucking through straw, inflating balloon, smoking, avoid singing

Small OACs <2mm usually heal with normal blood clot formation and routine mucosal healing

If large or lining torn: Close with buccal advancement flap

acute

20
Q

prognosis of OAC tx success depends on

A

size

small OACs <2mm usually heal with normal blood clot formation and routine mucosal helaing

if large or lining torn - close with buccal advancement flap

21
Q

management of small OAC

5 points

A

Inform patient

Encourage clot

Suture margins pack has risk of pushing into sinus

Antibiotic (area of debate)

Post-op instructions most important
* Minimising pressure formation within the sinuses and mouth
* Avoid blowing nose, avoid sucking through straw, inflating balloon, smoking, avoid singing

22
Q

post op instructions for pt with OAC

A

Post-op instructions most important
* Minimising pressure formation within the sinuses and mouth
* Avoid blowing nose, avoid sucking through straw, inflating balloon, smoking, avoid singing

23
Q

post op instructions for pt with OAC

A

Post-op instructions most important
* Minimising pressure formation within the sinuses and mouth
* Avoid blowing nose, avoid sucking through straw, inflating balloon, smoking, avoid singing

24
Q

pts with OAF may complain of

6

A
  • Problems with fluid consumption (fluids from nose)
  • Problems with speech or singing (nasal quality)
  • Problems playing brass/wind instruments
  • Problems smoking cigarettes or using a straw
  • Bad taste/odour/halitosis/pus discharge (post-nasal drip)
  • Pain/sinusitis type symptoms (discussed later)
25
Q

management of OAF

A

excision of sinus tract (like a tube)

raise Buccal Advancement Flap - same design as large OAC

antral washout - not always done
followed by same closure as OAC

chronic

26
Q

5 flap design options for OAC/OAF

2 main

A

**Buccal Advancement Flap **
* most common, but can fail esp in bigger communication

Buccal Fat Pad with Buccal Advancement Flap
* thicker flap, can be better for larger communication
* high in sulcus - yellow globular fatty tissue
* 2 layer closure rather than 1, can cause more bruising and more prominent cheek bone on one side

Palatal Flap
very painful, raw exposed bone on palate, thick tissue for flap coverage

Bone Graft/Collagen Membrane usually only when others failed

Rotated Tongue Flap (Historical)

27
Q

aetiology of fracture of maxillary tuberosity

5

A
  • Single standing molar
  • Unknown unerupted molar or wisdom tooth
  • Pathological gemination/concrescence
  • Extracting in wrong order
  • Inadequate alveolar support with non-dominant hand

Commonly involves maxillary sinus

27
Q

aetiology of fracture of maxillary tuberosity

5

A
  • Single standing molar
  • Unknown unerupted molar or wisdom tooth
  • Pathological gemination/concrescence
  • Extracting in wrong order
  • Inadequate alveolar support with non-dominant hand

Commonly involves maxillary sinus

28
Q

dx of maxillary tuberoisty #

4

A

noise

movement notes both visually or with supporting fingers

more than one tooth movement

tear in soft tissue of palate

29
Q

management options for fracture of maxillary tuberoisty

2 methods

A

Reduce and stabilise to tooth in front
* Orthodontic buccal arch wire with composite
* Arch bar
* Splints (lab-made) – challenge as need impression

Dissect out and close wound primarily
* Pulled too far from blood supply so no chance healing

30
Q

if splint the tooth remember to

5

A

Remove or treat pulp

Ensure it is out of occlusion

Consider antibiotic and antiseptics

Post-op instructions
* Similar to OAC instructions

Remove the tooth surgically 4-8 weeks later after bone healing

31
Q

suspect root/tooth in maxillary sinus - what to do

A

Confirm radiographically by OPT, occlusal, or periapical (+/- CBCT usually on day of retrieval)

Decision on retrieval
* If in doubt or retrieval difficult – refer

32
Q

best outcome if part of tooth/root end up in maxillary antrum

A

fractured part of floor of antrum but not torn lining of antrum, but accidentally pushed root up so wedged between lining of maxillary antrum and alveolar bone
* won’t cause sinusitis, pt issues or will move as wedged in place

So if pt doesn’t consent to further surgery it is least likely to cause problems (cannot guarantee none)

33
Q

retrieval options for root/tooth in antrum

3

A

OAF-type approach / through the extraction socket most common
* Open fenestration with care
* Suction – efficient and narrow bore
* Small curettes - careful esp if think lining isn’t breached yet
* Irrigation or ribbon gauze
* Close as for OAC

Caldwell-Luc approach
* Buccal/Labial sulcus
* Buccal window cut in bone more anterior to where root is and look downwardly posterior into sinus

ENT if unsuccessful or hard on radiograph
* Endoscopic Retrieval

34
Q

when you examine pt with maxillary discomfort remeber

A

close relationship of sinuses and the posteiror maxillary teeth

aetiology of paranasal sinus inflammation and infection

pt with sinusitis often present to the dentist first

35
Q

aetiology of sinusitis

A

Most are precipitated by the effects of a viral infection
* Inflammation and oedema
* Obstruction of ostia
* Trapping of debris within sinus cavity

Mucociliary clearance patterns may be altered by:
* Allergens
* Inflammation
* anatomic abnormalities

Normal physiological function is further disrupted by the cellular damage that occurs to the mucosal lining, this affects normal ciliary function

When the sinus can no longer evacuate its contents efficiently
* build up of pressure, also produce an area of stagnation in sinuses
* opportune situation for bacterial overgrowth of normal flora - leads to a bacterial infection –* opportunistic infection, viral initially*

36
Q

signs and symptoms of sinusitis

A
  • Facial pain
  • Pressure
  • Congestion (fullness)
  • Nasal obstruction
  • Paranasal drainage
  • Hyposmia (reduced sense of smell)
  • Fever
  • Headache
  • Dental pain
  • Halitosis
  • Fatigue
  • Cough
  • Ear pain (referred pain)
  • Anaesthesia / paraesthesia over cheek
37
Q

dental causes to rule out is sinusitis suspected

A

periapical abscess

periodontal infection

deep caries

recent extraction socket

TMD

neuralgia or atypical facial pain/chronic midfacial pain

38
Q

4 dental indicators for sinusitis

A

Discomfort on palpation of infraorbital region

A diffuse pain in the maxillary teeth

Equal sensitivity from percussion of multiple teeth in the same region
* Doesn’t make sense all TTP as no evidence of dental disease

Pain that worsens with head or facial movements

39
Q

3 tx aims for sinusitis

A

tx presenting symptoms

reduce tissue oedema

reverse obstruction of the ostia - allow drainage

40
Q

tx for sinusitis

A

Decongestants reduce mucosal oedema
* Ephedrine nasal drops 0.5% one drop each nostril up to three times daily when required (use for a maximum of 7 days)
* Effective but only short term use as cause atrophy of nasal lining

Humidified air is also helpful (steam/menthol inhalations)

Antibiotics for sinusitis should only be used if symptomatic treatment is not effective/symptoms worsen AND signs and symptoms point to a bacterial sinusitis
* Amoxicillin 500mg, three times a day, for 7 days (first line) OR
* Doxycycline 100mg, once a day, for 7 days (200mg loading dose)

check SDCEP guidance

40
Q

tx for sinusitis

A

Decongestants reduce mucosal oedema
* Ephedrine nasal drops 0.5% one drop each nostril up to three times daily when required (use for a maximum of 7 days)
* Effective but only short term use as cause atrophy of nasal lining

Humidified air is also helpful (steam/menthol inhalations)

Antibiotics for sinusitis should only be used if symptomatic treatment is not effective/symptoms worsen AND signs and symptoms point to a bacterial sinusitis
* Amoxicillin 500mg, three times a day, for 7 days (first line) OR
* Doxycycline 100mg, once a day, for 7 days (200mg loading dose)

check SDCEP guidance

41
Q

fungal infections sinusitis

A

very rare - if have a non-resolving sinusitis, check for this

can cause expansion of the bony walls by increase mucus secretion and fungal growth (happens in any long standing sinus infection)
* REFER TO ENT

42
Q

can trauma cause sinusitis

A

yes - by violating the integrity of the bony cavity and sinus membrane

e.g.
* Sinus wall fractures
* Orbital floor fractures
* Root canal therapy
* Tooth extractions
* Dental Implants/Sinus lifts (perforate sinus, reduce volume of max sinus to allow inc bony deposition for bone graft)
* Deep periodontal treatment
* Nasal packing
* Nasogastric tubes
* Mechanical (nasal) intubation

43
Q

possible traumas that can damage the sinus bony walls and membrane

can cause sinusitis
9

A
  • Sinus wall fractures
  • Orbital floor fractures
  • Root canal therapy
  • Tooth extractions
  • Dental Implants/Sinus lifts (perforate sinus, reduce volume of max sinus to allow inc bony deposition for bone graft)
  • Deep periodontal treatment
  • Nasal packing
  • Nasogastric tubes
  • Mechanical (nasal) intubation
44
Q

benign sinus lesions

A

can be chance findings on OPT

e.g. polyps, papillomas, antral pseudocysts, mucoceles and mucous retention cysts
or odontogenic cysts/tumours expanding into maxillary sinus

45
Q

malignant lesions in maxillary sinus

A

rare

primary tumous e.g. of the bone or lining

or local spread from adjacent sites e.g. SCC of maxilla invades the sinus

BDS4 CDS Oral Surgery (19 decks)

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