Maxillary Sinus Flashcards
What sinuses can transillumination be used for?
- Frontal.
- Maxillary.
What is the management for acute infective sinusitis?
In most fit and healthy adults (no immunocompromise) this should be SELF-LIMITING thus inhalations recommended
- Inhalations 3 times a day for 1 week(ex. menthol).
- Epinephrine nasal drops 0.5% 2 time a day for 1 week.
- Penicillin V 500mg 4 times a day for 7 days.
- Doxycycline 10mmg for 1 week, 200mg on first day.
What happens if a patient completes a round of antibiotics to treat maxillary sinusitis yet this fails?
Likely undergo 3D imaging to see if there is some obstruction.
What is chronic sinusitis? What often causes it?
- Ongoing, low-grade symptoms.
- Often indicates a MECHANICAL obstruction (ex. deviated septum).
How to assess for OAC and consent (4)?
- Extracting any upper molars (especially P root) and occasionally premolars.
- If the film suggests a close relationship.
- Inform the patient of the risk, what to expect if this happens.
- Outline how the complication is managed.
Calcified material in the antrum?
Antrolith.
When does the maxillary sinus stop growing?
Continues enlarging as we get older, thus increases the risk of OAC and fractured tuberosities.
When is a CT/ MRI indicated for a maxillary sinus?
When you are worried something is occupying the sinus.
5 bacterial species associated with acute infective sinusitis?
- Strep pneumoniae.
- H.Influenzae.
- Moraxella catarrhalis.
- Staph aureus.
- Alpha hemolutic strept
What would you see clinically after XLA when an OAC has been formed?
- CANNOT see base of socket.
- Will not hold a clot and base will look dark as you are looking into the antrum.
- Communication CLINICALLY APPARENT, will not hold a consolidating clot.
Another name for maxillary sinus?
Sinus of highmore
Why do we ask patients to avoid nose blowing after OAC treatment?
Blowing air through the antrum can place pressure on the wound and cause WOUND BREAKDOWN.
What is it called when the maxillary sinus lining stays intact but falls down?
Antral lining collapse.
3 serious complications of sinusitis?
- Brain abscesses.
- Orbital cellulitis.
- Cavernous sinus thrombosis.
What is it called when all the sinuses become infected?
PANSINUSISITIS due to the proximity of the draining osteum from the sinuses.
8 clinical symptoms of acute infective maxillary sinusitis?
- Pain.
- Tenderness worse on bending.
- Maxillary posterior teeth TTP/ maxillary tooth toothache.
- Bad taste/ smell.
- Post nasal drip.
- Mucopurulent nasal discharge.
- History of coloured discharge.
- Poor response to decongestants.
How is endoscopy applied to maxillary sinuses?
Small endoscope placed through the ostium on the lateral wall of the nose to view the sinus.
What is an antral tap?
Uses a small instrument to make a hole in the antrum to drain it - NOT DONE OFTEN NOAWADAYS.
5 symptoms of OAC?
- Passage of fluid down nose.
- Passage of air into mouth.
- Alteration of voice.
- Unilateral epistaxis.
- Nasal obstruction.
Mucocele in the antrum?
Antrocele.
What is the management for chronic sinutitis?
- Antral lavage (wash out antrum).
- Intranasal antrostomy (increase the size of the ostium).
- Metronidazole with amoxicillin, erythromycin.
- If OAF must surgically close defect.
What are antral mucoceles? What is their clinical importance?
- CYSTS.
- Can become so large that they obstruct the ostium, causing mechanical blockage and CHRONIC SINUSITIS.
How does the maxillary sinus drain?
- Drains into the MIDDLE MEATUS through a 2.4mm OSTEUM which is 2/3rds up the MEDIAL wall of the sinus.
- Thus mucous must go AGAINST gravity.
4 common pathologies of the maxillary sinus?
- Infective maxillary sinusitis.
- Non infective maxillary sinusitis.
- Fractures (maxilla or zygoma).
- Tumors/ cysts.
Increase the size of the ostium?
Intranasal antrostomy.
How is the displacement of a tooth/ tooth piece into the maxillary sinus managed?
Managed SURGICALLY by removing the foreign body and closing the OAC.
4 causes of OAC?
- XLA of maxillary posterior teeth.
- Tuberosity fracture.
- Middle third fracture.
- Pathology/ malignancy
How is OAC managed (4)?
- Ideally close immediately using BUCCAL ADVANCEMENT FLAP.
- Plate or modified denture.
- Antibiotics, epinephrine frops and mucolytic inhalations to avoid developing sinusitis.
- Avoid nose blowing.
what % of acute infective maxillary sinusitis is of dental origin?
10%
What is a PATHOGNOMONIC SIGN OF OAC?
Fluids coming down the nose after drinking.
What teeth are close to the maxillary sinus?
Maxillary molars and premolars.
- Especially PALATAL roots of MAXILLARY MOLAR TEETH.
7 functions of the paranasal sinuses?
- Humidification of inspired air.
- Filtering the air.
- Production/ quality of voice.
- Lightening the head.
- Crumple zone of the face.
- Olfactory sense.
- Immunological defense role.
2 reasons why someone may be predisposed to recurrent sinusitis?
- Mechanical obstruction (polyp, deviated septum, oedema of nasal mucosa).
- Impaired mucous clearance (poor ciliary action, abnormally thick or sticky mucous).
What are the paranasal sinuses?
- Air-containing sacs lined by ciliated epithelium, communicating with the nasal cavity.
- Frontal, ethmoidal, sphenoidal, maxillary.
What would you see on radiograph if a maxillary sinusitis?
- Opaque sinus.
- Fluid level.
Where do the paranasal sinuses drain into?
All drain into the LATERAL WALL OF THE NOSE.
What is the scheiderian membrane?
The lining of the maxillary sinus.
What is the shape and volume of the maxillary sinus?
- PYRAMIDAL shape.
- Volume 15-30mls.
What kind of epithelium lines the maxillary sinus?
Respiratory epithelium.
What causes infective sinusitis?
Can be bacterial, viral, fungal.
Most sinusitis follow from a VIRAL infection (ex. cold/flu). Inflamed sinuses and buildup of mucous, it becomes BACTERIALLY infected.
Wash out the antrum?
Antral lavage.
How does sinus pathology produce symptoms like toothache?
- Toothache affecting upper quadrant that patient finds difficult to localize.
- Inflammation in sinus causes stimulation of the MAXILLARY DIVISION OF THE TRIGEMINAL NERVE which innervates both the teeth and sinus.
What patients are at higher risk of OAC?
Elderly, partially dentate patients who undergo XLA of upper molars/ premolars (due to pneumatization of maxillary antrum).
Why does maxillary sinusitis pain get worse on bending?
Mucopurulent materials sits on top of the ANTERIOR SUPERIOR ALVEOLAR NERVE, pressing it and making pain worse.
2 impaired mucous clearance causes of the maxillary sinus?
- Poor ciliary action.
- Abnormally thick or sticky mucous (cystic fibrosis).
A clinical test that can help assess the maxillary sinus?
TRANSILLUMINATION.
- Endoscope with a light source placed up the pts nose.
- Illuminates –> healthy.
- Less bright –> pathology, would likely see the outline if there is something in the sinus.
Can be done for FRONTAL and MAXILLARY sinuses.
4 peri-operative complications associated with dentistry and the maxillary sinus?
- Extrusion of endodontic material .
- Oro-antral communication.
- Displacmeent of tooth/ pieces into the sinus.
- Fracture of maxillary tuberosity (large OAC).
2 ways in which sinus pathology can present in the mouth?
- Cancer of maxillary antrum can cause EROSION of bone into the mouth.
- CYST in the antrum can enlarge and DISPLACE TEETH.
How does mucous from the sinuses drain?
Ciliated epithelium beats in SPIRALING PATTERN to OSTIUM.
Why do nasal decongestants work poorly for acute infective maxillary sinusitis?
Osteum is small (2.4mm) + thickened scheniderian membrane narrows it even more –> cannot get in.
What can happen when a foreign body (ex. endodontic material) enters the sinus?
- Foreign body into STERILE cavity.
- Inflammatory reaction and likely INFECTION.
- Thus **SINUSITIS*.
When may an OAC spontaneously close?
If around 5mm.
What imaging is recommended for maxillary sinuses (6)?
- Occipitomental (Water’s view).
- DPT, periapicals.
- CT scan, MRI.
- Endoscopy
3 mechanical obstruction of the maxillary sinus?
- Deviated septum.
- Polyps.
- Oedema of nasal mucosa.
What is the pathognomonic sign of acute/chronic sinusitis?
Pain gets worse when the patient bends forward.
Tooth fragment causes obstruciton of osteum and thus drainage. Acute or chronic sinusitis?
Chronic.
How is a sinusitis confirmed?
Through CLINICAL SIGNS and SYMPTOMS.
- NOT recommended to take a radiograph.
4 types of non infective sinusitis?
- Allergic.
- Vasomotor.
- Septal deviation predisposes.
- Foreign body (teeth/ roots).
What is the membrane of the maxillary sinus called?
SCHNEIDERIAN MEMBRANE, 0.25mm thick.
What is chronic sinusitis suggestive of (2)?
- IMMUNOCOMPROMISE (in the absence of OAF).
- Possible anatomical drainage problem (ex. deviated septum).
What happens after an OAC?
- Often maxillary sinusitis.
- If left antreated will form an epithelial line tract (OROANTRAL FISTULA) which could lead to CHRONIC SINUSITIS.
What would you see clinically after XLA when an OAC has NOT been formed?
- Can see the base of socket.
- Can see a healthy blood clot forming at the base.
3 reasons why the maxillary sinus is important for dentists?
- Common peri-operative complications.
- Sinus pathology can cause symptoms like toothache.
- Sinus pathology can present in the mouth.
Where does the maxillary antrum drain into? Why is this important?
Drains into the MIDDLE MEATUS.
- Underneath the frontal drainage, thus infection in the frontal sinus can co-infect the ethmoidal and mxillary sinuses.
What happens if OAC is left untreated (5)?
OAF forms:
- Persistent sinusitis.
- Unilateral nasal discharge.
- Intra-oral antral polyp.
- Cacogeusia.
- Facial pain.
What innervates the maxillary sinus?
Second (maxillary) division of the trigeminal nerve
How is a root lodged in the maxillary sinus usually removed?
Endoscopically by the ENT.
