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MAXILLARY AIR SINUS: Introduction Function of air sinus Anatomy & Histology of maxillary air sinus Clinical importance of maxillary air sinus Disease of the maxillary sinus Infection- 1. Acute maxillary sinusitis 2. subacute maxillary sinusitis 3. Chronic maxillary sinusiti communication- 1. Acute oroantral fistula 2. Chronic oroantral fistula - Etiology - clinical features - Investigation - management

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AIR SINUS These are air filled hollow space present within the bone around the nasal cavity called as paranasal air sinuses. The sinuses are – (1) Frontal air sinus (2) Maxillary air sinus (3) Sphenoidal air sinus (4) Ethmoidal air sinus These sinus forms various boundaries of the nasal cavity & all these sinus communicate with each other and open into the lateral wall of the nasal cavity.

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FUNCTION OF AIR SINUS : The function of air sinus are Humidification of inspired air It provides resonance to voice. It lightens the bone. It act as thermal insulator to protect organ such as the eye and cranium from variation in intranasal temperature. Sinus increase the surface area of the skull.

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MAXILLARY AIR SINUS : Definition: An antrum is a hallow cavity within the bone called maxillary air sinus. Maxillary air sinus known as antrum of Highmore, named after an english antomist Nathaniel Highmore who was described it. It is one of the largest paranasal sinus. ANATOMY OF THE MAXILLARY AIR SINUS : It is basically pyramidal in shape with the base of the pyramid forming the lateral nasal wall and apex at the root of the zygoma. Capacity : 10-15 ml (in adult antrum) Size : Dimension of sinus are Height – 3.5 cm Width – 2.5 cm Anteroposterior Depth – 3.2 cm

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ROOF OF THE ANTRUM : - Formed by floor of the orbit. - Thin plate of orbital plate of maxilla. - It lodges the infraorbital canal and groove which lodges the infraorbital nerve. FLOOR OF THE SINUS: - Alveolar process of the maxilla. - its level is lower than the level of the floor of the nose. - Closely related to root apices of the maxillary premolar and molar.

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ANTERIOR WALL: -Formed by the facial surface of the maxilla. - Canine fossa is an important structure of this wall. POSTERIOR WALL: - Formed by sphenomaxillary wall. - A thin plate of bone separate the antral cavity from the infratemporal fossa. MEDIAL WALL : - Lateral wall of the nasal cavity. - the opening of the antrum in the middle meatus at the lower part of the hitus semilunaris. - The opening of the sinus is closer to the roof and thus at a highr level than the floor.

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HISTOLOGY OF THE MAXILLARY AIR SINUS: - the sinus is lined by respiratory mucosa which is lined by ciliated columnar epithelium. The ciliated movement help in removal of mucus secretion towards the osteum. BLOOD AND NERVE SUPPLY: Arterial supply : - Facial artery - Infraorbital artery - Greater palatine artery Venous drainage: - Facial vein - pterygoid venous plexus

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Lymphatic Drainage : - sumbmandibular lymph node. Nerve supply: - Infraorbital nerve - Anterior superior alveolar nerve - Middle superior alveolar nerve - posterior superior alveolar nerve

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EMBRYLOGY: The sinus are rudimentary or even absent at birth. They enlarge rapidly at the age of 6 to 7 months. The maxillary air sinus formed first among the other paranasal sinus. It start as a shallow groove on the medial surface of the maxilla during the fourth month of intrauterian life. Present as small cavity at birth. From birth to adult life the growth of sinus due to enlargment of bone. It reach maximum size by around 18 years of age. In old age it enlarge due to resorption of the surrounding cancellous bone.

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CLINICAL IMPOTANCE ; Dental infection: Infection from the maxillary premolar and molars can easily communicate and infect the maxillary antrum. Oroantral Communication: Traumatic extraction of maxillaryteeth can cause oroantral communication. Root Pieces: Root pieces of maxillary teeth may sometimes be accidentally forced into the maxillary antrum. Maxillary Sinusitis : Because of the thickned and inflammed sinus lining compresses the nerve supply of the maxillary posterior teeth causing tenderness of the maxillary teeth. The Maxillary Artery can be approached through the posterior wall of the maxillry antrum for ligation. The infraorbital and superior alveolar vessels are freqently ruptured in maxillary fracture causing the hemotoma formation in the antrum.

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MAXILLRY SINUSITIS maxillary sinusitis: It is the inflammation of the maxillary sinus. Maxillary sinusits Acute Subacute Chronic ACUTE SINUSITIS: It may be supurrative or non supurrative inflammation of the antral mucosa. It is the most freqently infected of the paranasal sinus.

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ETIOLOGY: (1)Nasal Infection (most common) : Viral rhinitis and influenza are the common infection. (2) Dental Infection: Infection from the maxillary posterior teeth can easily spread to the maxillary sinus as the plate of bone dividing the root apices from the sinus . (3)Contaminated Swimming water : Diving in such water forcibly directs water into the nasal cavity and then into the sinus. (4) Trauma: Fracture of the maxilla or zygoma, gun shot wound or penitrsting injuries can lead to sinusits.

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PATHOGENESIE: During early phase of inflammation, intial vasodilation leads to increases production of mucosa from the mucosa gland. The mucosa concequently exert pressure within the lumen of the antrum.

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CLINICAL FEATURES: The patient gives history of `catching cold’ 3 to 4 days earlier. Nasal block secondary to rhinitis. Increase in purulent, thick, discoloured and foul smelling nasal discharge is prominenant features. A sense of fullness and pain on cheek on bending forward. Patient producing cough secondary to the nasal discharge with onset of pharyngitis. The related maxillary teeth are tender on percussion. Nasal resonance- change in the voice due to blocking of sinus. Constitutional symptoms – Fever, Headache, Malaise, Difficulty in breathing.

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DIAGNOSIS; (1) Water view radiograph. (2) Transillumination test: Shows opacity involved sinus. (3) Culture: Nasal secretion may be for culture sensitivity test to see the organisam involved. MANAGEMENT: MEDICACAL SURGICAL MANAGEMENT MANAGEMENT

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MEDICAL MANAGEMENT: Antibiotics: Broad spectrum antibiotics. Decongestant: Decreases the congestion and edema of the nasal sinus. Help in the drainage of the sinus. Analgesics: Paracetamol provide symptomatic relief. Steam inhalation: Steam+ Menthol+ Tincture. After Decongestion for 15 to 20 minutes. Helps in drainage. Hot Fomentation: Local heat application is soothing to the inflamed sinus.

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SURGICAL MANAGEMENT: Antral levage: Acute maxillary sinusitis usually responds well to medication. It is basically involves inserting a canula into the maxillary sinus trough the inferior meat us. Luke warm water is irrigated through the sinus and this drains out through the osteum along with the sinus exudates. COMPLICATION - Chronic sinusitis - Osteomylelitis of the maxilla - Orbital cellulites - Middle ear infection - Spread to the other sinus.

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SUBACUTE MAXILLARY SINUSITIS: It is the intermediate stage between acute and chronic sinusitis. There is pain only in the form of the local discomfort. patient has persistent discharge. The voice is nasal, throat is sore with constant irritating cough. Patient can not sleep well. The disease may take a long course over week or months.

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CHRONIC SINUSITIS Infection of the that last for months or year is called chronic sinusitis. It is most commonly is an extension of an acute sinusitis which failed to resolve completely. CAUSATIVE ORGANISM: - Aerobic organism - Anaerobic organism.

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PATHOPHISIOLOGY: After infection Ciliated epithelium gets destroyed Prevent drainage of secretion from the maxilla pooling and stangnation of mucopurulent in sinus Progression of infection Mucosa changes Cilliary damaged and edema Mucosa may become thick and polypoidal.

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Clinical Features: Symptoms are non specific unlike acute sinusitis. patient not having pain or tenderness. Purulent nasal discharge may be foul smelling. Block of nasal and change in voice due to loss of resonance. Ansomia. INVESTIGATION Water’s view radiograph. Culture of the discharge from the sinus. Transillumination test.

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MANAGEMENT: Medical management: Antibiotics: Broad spectrum antibiotics. Analgesics: Paracetamol providing relief. Decongestant . Steam inhalation. Hot fomentatiom.

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SURGICAL MANAGEMENT: Treat any dental infection if present. Antral leavage: If more than three successive punture have purulent fluid than the treatment should be more radical. Intra nasal Antrostomy : A window or opening is created in the inferior meatus of facilltates drainage of the sinus. Cold Well luck Operation.

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CALDWELL LUC OPERATION: This is the procedure by which the antrum is entered intraorlly through the anterior wall and all irreversible disease is removed. This is followed by an antrostomy to promote permanent cure. INDICATION: Chronic maxillary sinusitis. Removal of foreign bodies in the antrum such as root pieces. Treatment of oroantral fistula that fails to heal. treatment of benign dental cyst tumor. Biopsy procedure for a suspected malignancy in the antrum. Recurrent antrachoanal polyp. Approach to pterygopalatine fossa, sphenoidal sinus, ethmoidal sinus.

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CONTRAINDICATION: Age- Not performed in patient below 17 years as there may be damage to devloping tooth bud in that region. Acute infecion. Other systemic cause contraindicating surgery. PROCEDURE: procedure is usually under general anesthesia. Patient is placed supine with head end of the table raised. Head is turned slightly to the opposite side. Incision: A semilunar incision is placed in the mucobuccal fold.

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Exposure: A full thickness mucoperiostel flap is reflected upto the infraorbital nerve. Care is taken to protect the infraorbital nerve. Approach to the antrum: A micromotor with the large round burr is used to create a window about 1.5 to 2 cm in the anteroir wall of the antrum. The sinus mucosa is seen below the bone. Antral lesion: The lesion may be delt with. A biopsy may be done or sinus mucosa is removed with the help of the curette as the case demand. Antrostomy: A opening is made in the medial wall in the lower most and anterior aspect of the inferior meatus.

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(8) Packing: The sinus cavity may be packed with the ribbon gauze impregnated with vaseline. The gauze is packed in layer and the free end is brought out through the created antrostomy opening. (9)Sutures: The bone margin is smoothened and the flap is replaced. The flap may be sutured using resorbable suture material.

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POST OPERATIVE CARE: Ice pack over the cheek for first few hour after surgery. Sinus pack is removed after 24 to 48 hours. Avoid blowing of the nose for at least 2 week after surgery. COMPLICATION: Intraoperative complication: Bleeding Damaged to infraorbital nerve. Damaged to orbital content- Due to perforation into the thin orbital floor during curettage of the superior wall of the trauma. Postoperative complication; Reactionary Heamorrhage. Infection. Numbness in the infraorbital region. Recurrence of the lesion. Antrstomy opening. Oroantral Fistula (rarely)

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OROANTRAL FISTULA: Definition: It is the pathological communication between oral cavity and maxillary antrum. Fresh communication will lake the epithelium lining while long standing ones known as chronic oroantral fistula have epithelized fistulous tract. OROANTRAL FISTULA ACUTE CHRONIC

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ETIOLOGY: Extraction of teeth: - Occurs as a result of a traumatic extraction of maxillary posterior teeth whose root may be inclose proximity to the floor of the maxillary antrum. - Tuberosity fracture as a result of upper third molar extraction. - In advert curettage of maxillary tooth socket. Facial Trauma: Maxillofacial trauma and penitrating injury. Surgical removal of the cyst and tumor associated with the maxillary alveolar region extending into the antrum. Osteomylities of the maxilla or following irradication. palatal gumma (syphilis) Malignant tumor such as wegenere’s granulomatosis wich may perforate the palate. Implant surgery in the maxillary posterior region.

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ACUTE OROANTRAL FISTULA: Clinical features: Symptoms- History of recurrent surgery in the vicinity of maxillary sinus. Escape of air and fluids through the nose and mouth. Unilateral epsitaxis. pain may be severe throbbing ordull aching pain. Enhanced column of air causing change in the vocal resonance and consequently change in the voice. IMIDIATED SIGN- The part of the bony part of the sinus may be adhearent to the root tip on extraction. Maxillary tuberosity fracture. Root tip in the maxillary antrum.

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DELAYED SIGN OF OROANTRAL FISTULA: Discharging of foul smelling pus from the fistula. Maxillary sinusitis. Infraobital region is tender on palpation. Infraorbital edema. Teeth an affected side will be tender on percussion. Nasal congestation around the osteum. Pus in the posterior wall of the pharynx. Antral polyp in the oral cavity.

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DIAGNOSIS OF OROANTRAL FISTULA: - A large fistula is easily seen on inspection. - Nose blowing test: The patient is placed to close his nostril and blow gently down the nose with nose open. Whistling sound as air passes down the fistula in the oral cavity. - cotton wisp test: The escape of air through the nose can be tested by placing a wisp of cotton near the orrifice. - Mouth mirror fogging test: A mouth mirror placed at the oroantral fistula causing the fogging of the mirror. - Unilateral epistaxis may sometimes be seen - some time the oroantral fistula can blocked by the an antral polyp.

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MANAGEMENT: Aim: - To prevent nasal regurgitation of fluides. - To prevent infection of the maxillary antrum from the oral cavity. CLOUSURE OF OROANTRAL COMMUNICATION: Aim: - Primary repair to close the communication. - Antibiotics to cure the sinus infection PROCEDURE: Irrigation of the antrum with saline. Simple suturing of the socket. A well fitting denture base may be constructed with a flenge extention to cover the oppening completely. This prevent contamination of the oral cavity and antral cavity and thus enabled healing. Once a communicate is formed between the oral and antral cavity, ther are the chance of infection of the maxillary antrum. Supportive measure are required for treatment of the maxillary antrum infection.

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SUPPORTIVE MEASURE: Antibiotics: -For prevent the sinusitis. - For preventing the infection. Steam inhalation: Steam inhalation with benzoin compound helps to thin down the antral section and helps in the easy drainage of these fluids through the nose.. Nasal Decongestant: - for reduce nasal secretion. - Decrease the nasal inflammation of the nasal mucosa. Analgesics and Antihistaminics: -For reduction of the pain - Decrease the secretion. Antral leavage:- When an accumulation of pus is suspected in the antrum it may be necessary to wash out the antrum with either warm normal saline or antibiotic rinse. Procedure is done at the regular interval till a clear fluid is obtained from the antrum.

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CHRONIC OROANTRAL FISTULA: This occur due to the persistence of the communication between the oral cavity and the maxillary antrum. CLINICAL FEATURES: Persistent unilatral foul discharge. Post nasal drip with the discharge trickle down the phrynx from the posterior nares resulting in foul smell and unpleasent test. Systemic sequeles due to swallowed pus in the form of -Pyrexia, malaise, Headache, Ansomnia,Anroxia. Pain is diminish consiberabely. Polyp projecting form the antrum into the oral cavity prevents the fistulous tract to heal spontaneosly.

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INVESTIGATION: - Intra oral periapical radiograph is taken with the silver probe placed into the fistula tract to determine the frequency of the tract. - Maxillary sinus radiograph of the skull. - Routine evalution. MANAGEMENT SURGICAL SUPPORTIVE METHOD METHOD

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SURGICAL METHOD If fistulous persist for more than 2 to 3 months the fistula tract would have been epithelized. METHOD OF CLOSURE TECHQUINE; LACAL FLAP 1. Buccal flap – Buccal advancement flap - Buccal sliding trepezoid flap - Bipedic flap 2. Palatal Flap- Palatal advancement flap - Palatal rotational advancement flap Submucosal connective tissue pedicle - Pedicle island flap - Anterior based flap 3. Combination of buccal and palatal flap DISTANT FLAP GRAFT- Buccal fat pad - Bone graft.

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PRINCIPLE : 1. Blood supply should be adequate so that the flap does not necrose. 2. Suture line is well supported by normal bone. 3. Wound is sutured in tension. 4. All basic requirement should be fullfilled. BUCCAL ADVANCEMENT FLAP: (VON REHRMANN FLAP) Described by Von Rehrmann in 1936. Mostly is used method. TECHQUINE: Excise the tissue lining the oroantral fitula. Two vertical divergent incision are made on either side of the fistula on the buccal gingiva. A broad based mucoperiosteum flap then elevated from the under lying bone and flap is mobilized to cover the oroantral communication.

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4. If the extent of the flap is inadequate the periosteum and the inner side of the flap may be incised horizontaly. the flap now be sutured more easiley. 5. The flap is made to cover the opening and is sutured to the palatal tissue. ADVANTAGE: 1. Simple and easily to perform. 2. Flap is usually has a good blood supply due to broad base. 3. Well tolerated by the most patient. 4. Denture may be placed immediately DISADVANTAGES: Reduction in the buccal vestibular depth.

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PALATAL ADVANCEMENT FLAP: Procedure: The palatal tissue surrounding the oroantaral communication may be advanced and sutured to the buccal tissue o cover the defect. The surface marking is midway between the free gingival margin and midline of the palate. The palatal mucoperiosteal flap with greater palatine vessles is raised its bed and roteted across the fistula with greater palatine foramen as the center of rotation Incision is made with the B.P. blade no. 11, the fistulous tract at least 2mm away from the epithelized surface. It is desected and removed out. Surface line rest on the normal bone. Flap design and length of the flap are determined. Depending on the length of the flap is raised carefully since the survival of the flap entirely depends on the vuscularitiey. The flap is rotated buccaly with greater palatine foramen as the centre of rotation to the extent needd to cover the fistula.

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DISADVANTAGE: - Palatal tissue is not very elastic and cannot be streached to cover the defect completely.

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ROTATIONAL ADVANCEMENT FLAP: This is posteriorly based flap which gets its blood supply from greater palatine artery. It has the advantage greater mobility and bulk. The flap is reflected and rotated to fit the defect. Chance of bending of the tissue when it is truned to cover the oroantral opening. This may be damaged due to venous congestion. To prevent the bending a V- shaped excision of the tissue at the bend may be done. This prevent the folding of the tissue at the junction. Then sutured to the buccal side with minimal tension.

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SUBMUCOSAL CONNECTIVE TISSUE PEDICLE: The submucosa on the palatal is used to cover the oroantral communication. The mucosa layer or the epithelial layeris then packed back on the donor site. Therefore there is no row surface on the palatal unlike the previous procedure. The dissection of the submucosa is however is difficulty procedure and required great care.

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COMBINATION PROCEDURE: A combination has been described where in alveolar bone based buccal flap is reversed and sutured with palatal margin. This replace the living part of the wound. The palatal flap is rotated and palaced in the usual manner. Thus the row surface of both the flaps are placed against each other. this is two layerd closure.

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DISTANT FLAP : Tongue Flap: Highly vascular and provide adequate bulk for the closure of large defects without tension. Disadvantages: Mobility of the tongue which can result in failure of flap.

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GRAFT PROCEDURE : 1. Buccal fat pad- small to medium sized defect can be closed with a buccal fat pad graft. It is simple surgical technique with the donor site being closed to area of closure. 2. Bone graft Allopalstic material : - Gold foil / gold plate : Gold foil can be used to bridge between the buccal and palatal flap till the defect heals. - soft polymethylmethacrylate - Hydroxyapatite blocks

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References Textbook of oral and maxillofacial surgery - chitra chakravarty Text book of oral and maxillofacial surgery - B.shrinivasan Text book of oral medicine - Anil govindrao Ghom

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