Maxillary sinus: complications and clinical significance Flashcards
what main sinuses are there in the face
what sinuses are larger at birth
maxillary and ethmoid
(spenoid and frontal undergo expansion during first few years)
funcations of the paranasal sinuses
- resonance to the voice
- reserve chambers for warming inspired air
- reduce the weight of the skull
anatomy of the maxillary sinus
- usually, largest of the sinuses
- pyramid-shaped cavity within the body of each maxilla
- around 15ml space in average adult
- 37mmx27mmx35mm
what is the opening of the maxillary sinus called and where is it
middle meatus (4mm in diameter)
superiorly on medial wall of sinus
what is the relationship of the maxillary antrum to the upper teeth
- the alveolar canals that transport the posterior superior alveolar vessels and nerves to the maxillary posterior teeth are generally found on the posterior wall of the sinus cavity
- roots of max molars and sometimes premolars may project into the floor of the max sinus
- roots may perforate the bone so that only the mucosal lining of the sinus covers them
what epithelium makes up max sinus
psuedostratified ciliated columnar epithelium
what role do the cilia play in the max antrum
- mobilise trapped particulate matter and foreign material within sinus
- move this material toward the ostia for elimination into the nasal cavity
clinical significance of the max sinus
- Oro-antral communication (OAC)
- oro-antral fistula (OAF)
- root in the antrum
- sinusitis
- benign lesions
- malignant lesions
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 OAC)
- direct vision
- good light and suction (echo)
difference between OAC and OAF
- OAC - just happened
- OAF - chronic problem, epithelium lined tract formed
what does an at risk radiograph in pre-op assessment look like for OAC
what is this
OAC
what is this
OAF
OAC management - acute
- inform patient
if small:
- encorage clot
- suture margins
- antibiotic?
- post-op instructions in particular, minimise pressure formation within sinuses and mouth
- avoid = sucking through straw, inflating balloons, blowing nose, smoking if possible, singing
if large:
- close with buccal advancement flap
describe buccal advancement flap
- 3-sided (2 relieving, 1 crestal)
- raise full thickness
- sometimes need to trim alveolar bone
- incise the periostium to avoid pulling under tension
- suture
CO for patients with chronic OAF
- problems with fluid consumption (fluids from nose)
- problems with speech/ singing (nasal quality)
- problems with brass/wind instruments
- problems smoking cigarettes/using straws
- bad taste/odour/ halitosis/pus discharge
- pain/sinusitis type symptoms
surgical management of OAF
- excision of sinus tract prior to performing buccal advancement flap
- sometimes need antral washout as can be infected
flap design options
- buccal advancement flap (most common)
- buccal fat pad with buccal advancement flap
- palatal flap
- bone graft/collagen membrane
aetiology of fracture of max tuberosity
- single standing molar
- unknown unerupted molar/wisdom tooth
- pathological gemination/concrescence
- extracting in wrong order
- inadequate alveolar support
diagnosis of fractured tuberosity
- noise
- movement noted visually/with supporting fingers
- more than 1 tooth movement
- tear in soft tissue of palate
management of fractured tuberosity
- reduce and stabilise (splints or ortho buccal arch wire with composite)
- dissect out tooth and close wound primarily
if you splint the tooth due to fractured tuberosity what do you need to remember to do
- remove or treat pulp
- ensure it is out of occlusion
- consider antibiotic and antiseptics
- post-op instructions
- remove the tooth surgically 4-8 weeks later
how would you confirm there is a root or tooth in the max sinus
- OPT, occlusal or periapical (+/- CBCT)
if a root was here, would you need to remove?
Not always
- won’t cause sinusitis
- won’t move
- haven’t torn lining
what methods are there for retrieving a root in the max sinus
- OAF type approach/through the extraction socket
- Caldwell-Luc approach (buccal window cut in bone)
- ENT (endoscopic removal)
what is the aetiology of sinusitis
- most precipitated by effects of a viral infection
- mucocillary clearance patterns altered
- build up of pressure
- opportune situation for bacteiral overgrowth of normal flora
signs and symptoms of sinusitis
- facial pain
- pressure
- congestion
- nasal obstruction
- paranasal drainage
- hyposmia
- fever
- headache
- dental pain
- halitosis
- fatigue
- cough
- ear pain
- anaesthesia/paraesthesia over cheek
what is important to rule out when you suspect sinisitis
dental cause:
- PA abscess
- periodontal infection
- deep caries
- recent extraction socket
- TMD
- neuralgia or atypical facial pain/chronic midfacial pain
benign sinus lesions
- polyps, papillomas, antral pseudocysts, mucoceles and mucous retention cysts
- odontogenic cysts/odontogenic tumours expanding into the maxillary sinus
malignant lesions
- primary tumours
- local spread from adjacent sites
indicators of sinisitis
- discomfort on palpation of infraorbital region
- diffuse pain in max teeth (all TTP)
- equal sensitivity from percussion of multiple teeth in the same region
- pain that worsens with head or facial movements
tx aims for sinisitis
- treat presenting symptoms
- reduce tissue oedema
- reverse obstruction of the ostia
tx of sinisitis
- decongestants reduce mucosal oedema (ephedrine nasal drops 0.5% one drop each nostril up to 3x daily when required - use for max 7 days)
- humidified air also helpful (steam/menthol inhalation)
would you use antibiotics for sinisitis?
ONLY if:
- symptomatic tx not effective/symptoms worsen
- signs and symptoms suggest bacterial sinusitis
if you were to prescribe antibiotics for sinisitis what would you prescribe
- amoxicillin 500mg, 3x daily for 7 days (first line)
- doxycycline 100mg, 1x daily for 7 days (200mg loading dose)
fungal infections are rare to cause sinisisits but what would happen if it did
- would be non-resolving
- expansion of bony walls by increased mucus secretion and fungal growth
what trauma can result in sinisitis
- sinus wall fractures
- orbital floor fractures
- RCT
- extractions
- dental implants/sinus lifts
- deep periodontal tx
- nasal packing
- nasogastric tubes
- mechanical (nasal) intubation
