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Surgical anatomy of maxillary sinus – note on (2)

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Surgical anatomy of maxillary sinus – note on (2)

  1. 1. Surgical anatomy of maxillary sinus – note on OAF - Dr. Dona Bhattacharya
  2. 2. Contents1. Introduction2. Embryology of maxillary sinus3. Anatomy of maxillary sinus4. Vascularization & innervation5. Microscopic anatomy6. Physiologic nature of mucus layer7. Drainage of sinus8. Functions of sinus9. Maxillary sinusitis10. Oroantral fistula11. Conclusion12. References
  3. 3. Introduction Paranasal sinuses  Air containing bony spaces present around the nasal cavity  Usually lined by respiratory mucus membrane  Four paired
  4. 4. Maxillary sinus Pneumatic space lodged in the body of maxilla that communicates with the external environment by way of middle meatus and nasal vestibule - by Orban’s Also known as antrum of Highmore (1651)
  5. 5. Embryology First sinus to develop Initial development of sinus follows number of morphogenic events in differentiation of nasal cavity
  6. 6. Embryology Horizontal shift of palatal shelves and fusion with one another Nasal septum separates 20 Oral cavity from nasal chambers Influence expansion of lateral nasal wall and 3 walls begin to fold Superior & inferior - Shallow depression for half of IU Life 3 conchae & meatus Middle - Expansion in lateral wall and in inferior direction
  7. 7. Embryology Development of sinus begins as evagination of mucus membrane in lateral wall of middle meatus when nasal epithelium invades maxillary mesenchyme ( Kitamura, 1989) Growth of sinus takes place by pneumatization  Primary (10th weeks)  Secondary (5th month)
  8. 8. Embryology Maxillary sinus has biphasic growth 0-3 years and 7-12 years Post natally grows @ 2 mm vertically and 3 mm AP Radiographically; triangular area medial to IOF (5th month) 3 growth spurts a) 0-2.5 years b) 7.5-10 years c) 12-14 years
  9. 9. Embryology
  10. 10. Embryology
  11. 11. Embryology
  12. 12. Embryology Developmental anomalies 1. Agenesis 2. Aplasia 3. Hypoplasia 4. Supernumary maxillary sinus
  13. 13. Anatomy Largest of PNS,communicate with other sinuses through lateral nasal wall. Horizontal Pyramidal shaped  Base  Apex  4 walls superior inferior lateral anterior  Wall thickness varies with individual
  14. 14. Anatomy Various shapes  Hyperbolic-47%  Paraboloid-30%  Semi-ellipsoid-15%  Cone shaped-8%  Dimensions (Therner, 1902)  H: 3.5cm  W: 2.5cm  L: 3.25cm  Vol:15-30 ml
  15. 15. Anatomy  Receses-  Alveolar  Zygomatic  Palatal  Frontal  Teeth in proximity 2nd, 1st , molar>3rd molar>2nd pm>1st pm>canine
  16. 16. Medial wall Formed by lat nasal wall  Below-inf nasal conchae  Behind-palatine bone  Above-uncinate process of ethmoid,lacrimal bone Contains double layer of mucous membrane(pars membranacea)
  17. 17. Medial wall Imp structures  Sinus ostium  Hiatus semilunaris  Ethmoidal bulla  Uncinate process  Infundibulum Applied aspect
  18. 18. Natural ostium Located in posterior ½ of infundibulum or behind lower1/3 of uncinate process. Tunnel shaped, length: 1- 22mm;3-6mm diameter Not detected endoscopically Unfavorable position for gravity dependent drainage Post edge-continuous with lamina papyracea(imp for surgical dissection)
  19. 19. Accessory ostium 2-3 in no.(30-40%) Bony dehiscences covered by mucosa(ant/post frontanelles)
  20. 20. Superior wall Forms roof of sinus and floor of orbit Imp structures  Infraorbital canal  Infraorbital foramen  ASA nerve Applied aspect  Vulnerable to trauma  Erosion of this wall by tumor
  21. 21. Posterolateral wall Made of zygomatic and greater wing of sphenoid bone(maxillary tuberosity) Thick laterally,thin medially Imp structures  PSA nerve  Maxillary artery  Maxillary nerve  Pterygopalatine ganglion  Nerve of pterygoid canal Applied aspect  Involvement of PSA-pain in post teeth  Surgical access by careful removal of segment of wall
  22. 22. Anterior wall Extends from pyriform aperture anteriorly to ZM suture & IO rim superiorly to alveolar process inferiorly. Convexity towards sinus Thinnest in canine fossa Imp structures  Infraorbital foramen  ASA, MSA nerves  Levator labii, obicularis oculi muscles Applied aspect
  23. 23. Floor of sinus Formed by junction of anterior sinus wall and lateral nasal wall 1-1.2 cm below nasal floor Close relationship between sinus and teeth facilitate spread of pathology Inner surface is rough by bony septa  Retrieval of root fragment  Interferes with sinus drainage
  24. 24. Vascularization & innervation a) Nasal Mucosal Vasculature SP, Ethmoid Arterial Supply b) Osseous Vasculature IO, PSA, ASA, GP, Facial a) Medial wall - SP Venous Drainage b) Other walls – Pterygomaxillary Plexus Lymphatic Drainage Collecting vessels in middle meatus Nerve Innervation ION, GP, PSA, MSA, ASA Clinical significance PO2 of sinus = 116 mm Hg
  25. 25. Vascularization & innervation
  26. 26. Microscopic anatomy 3 layers  Epithelium  Basal lamina  Sub epithelium
  27. 27. Epithelium Pseudostratified columnar ciliated epithelium Cells  Columnar ciliated  Goblet  Basal  Non – ciliated
  28. 28. Ciliated epithelium 100 motile and no. of immotile microvilli present along apical surface Function: mucus clearance along with entrapped debris from nose and PNS Ciliary motility dependent on ATP driven molecular motors cause outer doublets of axoneme to slide over each other All cilia beat together to form metachronous wave Each cilia has power stroke followed by recovery stroke
  29. 29. Ciliated epithelium
  30. 30. Microvilli Hair like projection of actin filament Length 1-2 mm Function:  Increase surface area of cell  Prevent drying of surface
  31. 31. Physiologic nature of mucus layer Sino nasal epithelium covered by mucus blanket Traps particles>0.5-1 um Composition  Water (95%)  Others (5 %)  Peptides  Salts  Debris Ph = 5.5-6.5
  32. 32. Physiologic nature of mucus layer 2 layers Inner sol Outer gel - Continuous -Discontinuous - Low viscosity - High viscosity - Surrounds shafts of cilia -Along ciliary tips
  33. 33. Drainage of sinus Mucus transported from nose and PNS to nasopharynx, ingested and presented to GIT (Messerklinger) Forms basis of fess
  34. 34. Drainage of sinus Flow of mucus superiorly against gravity Upward course along walls of entire cavity and then towards natural ostium in superomedial wall Drainage into ethmoidal infumdibulum Mucus coursing along lateral wall, carried medially along roof to reach ostrium Mucociliary flow from anterior sinuses converge at OMC, carried to posterior nasopharynx & inferiorly to eustachian tube orifice By Donald et al & Antunes et al
  35. 35. Drainage of sinus
  36. 36. Drainage of sinus Mucociliary flow Smooth:0.85 cm/minute Jerky: 0.3 cm/minute Mucostasis: <0.3 cm/minute
  37. 37. Basal lamina & subepithelium Contains serous glands and blood vessels Subepithelium – 10 serous Mucosa removal – 73% decrease in serous glands and 30% in goblet cells
  38. 38. Functions of sinus1. Decrease skull weight2. Impart resonance to voice3. Mucus production and storage4. Humidify and warm inhaled air5. Define facial contour6. Immunodefensive action7. Conserve heat from nasal fossae8. Moisturize air9. Filters debris10. Dampen pressure differential during inspiration11. Limit extent of facial injury from trauma12. Serves as accessory olfactory organ
  39. 39. Maxillary sinusitis Group of diseases mainly inflammation & infection which affect the nasal mucosa and PNS
  40. 40. Maxillary sinusitis
  41. 41. Maxillary sinusitis Anatomical variations influencing the development of sinusitis a) Variations of uncinate process b) Variations in bulla ethmoidalis c) Variations of middle turbinate d) Accessory ostium e) Deviated nasal septum f) Nasal masses g) Haller cell
  42. 42. Maxillary sinusitis Extrinsic Intrinsic causes 1. Infectious causes causes 1. Genetic a) Bacterial a) Structural b) Viral b) Immunodeficiency c) Fungal c) Mucociliary d) Parasitic abnormality 2. Non infectious (cystic causes fibrosis, dismotility) a) Allergic 2. Acquired b) Non allergic a) Aspirin hypersensitivity c) Pharmocologic b) Autonomic d) Irritants dysregulation c) Hormonal 3. Disruption of mucociliary drainage d) Structural (Tumors, cysts) a) Surgery e)Idiopathic/ b) Infection autoimmune c) Trauma f) Immunodeficiency
  43. 43. Maxillary sinusitis Diagnosis 1. History 2. Physical examination  Inspection  Palpation  Percussion  Diagnostic techniques a. Rhinoscopy b. Endoscopy c. Nasal valve examination d. Culture and sensitivity
  44. 44. Maxillary sinusitis Major & Minor Factor Associated with the Diagnosis of Chronic Rhinosinusitis Major Factors Minor Factors Facial pain/pressure Headache Facial congestion/fullness Fever (non-acute cases) Nasal obstruction/blockage Halitosis Nasal Fatigue discharge/purgulence/discol ored postnasal discharge Hyposmia/anosmia Dental pain Purulence in nasal cavity on Cough examination Fever (in acute rhinosinusitis Ear pain/pressure/fullness only)
  45. 45. Maxillary sinusitis3. Radiological examination a) OM view b) Caldwell view c) Lateral view d) CT scan e) MRI4. Tests for mucociliary functions a) Nasomucociliary clearance b) Ciliary beat frequency c) NO measurement d) Rhinomanometry5. Test for olfaction
  46. 46. Maxillary sinusitis Management Medical Surgical1. Antibiotics 1. sinus aspiration and lavage2. Steroids 2. Maxillary needle sinusotomy3. Decongestants 3. Caldwell luc4. Analgesics 4. FESS5. Antihistamines6. Nasal spray & saline irrigation7. Hydration8. Mucolytics(guaifenesin,KI)
  47. 47. Antibiotics Antibiotic Micro factors Pediatric dosageFirst line therapyAmoxicillin 45 mg/kg/day or 90 mg/kg/day divided 500 g BIDSecond line therapyAmoxicillin/potassium 22.5-45 mg/kg/day divided (dose based on 500-875 mg BIDcalvulanate amoxicillin component) 10 mg/kg/day on day 1, then 5 mg/kg/day 500 mg QID on day 1, then 250 mgAzithromycin on days 2-5 QID on days 2-5Cefdinir 14 mg/kg/day 300 mg BIDCefpodoxime 10 mg/kg/QID 200 mg BIDCefprozil 15 mg/kg/QID 250-500 mg BIDCefuroxime 15 mg/kg/QID 250 mg BIDCiprofloxacin 500 mg BIDClarithromycin 7.5 mg/kg/day 500 mg BIDCindamycin 8-20 mg/kg/day divided QID 150-450 mg BIDDoxycycline 100-200 mg QIDGarifloxacin 400 mg QIDLevofloxacin 500 mg QIDSulfamethoxazole/trimethop 6-12 mg/kg/day divided (based on 800-160 mg BIDrim trimethoprim)
  48. 48. Steroids 1st line of therapy: topical intranasal (betamethasone, dexamethasone, triamcinolone) Systemic steroids:  Prednisolone:0.5-1mg/kg x3-4 days
  49. 49. Decongestants Systemic (phenylpropanolamine, pseudoephidrine):  Contraindications: hypertension, hyperthyroidism, asthma Topical: phenylepinephrine HCl, oxymetazoline HCl  Adv. Effects- rhinitis medicamentosa
  50. 50. Analgesics & antihistamines Analgesics:  Opoid: acetaminophen, codeine  NSAIDS: Antihistamines:  Mequitazine, terfenad  Contraindicated in bacterial sinusitis  Adv effect: sedation
  51. 51. Nasal lavage & sprays m/a:  Removes debris & dead tissue  Washes inflammatory secretions  Eliminates nutrient source Methods:  Lavage pot  Syringe  Irrigating bulb
  52. 52. Nasal lavage & sprays Techniques of nasal sprays 1. Moffet position 2. Mygind technique
  53. 53. Surgical management Indications Contraindications • Bilateral chronic • Presence of sinusitis with polyps extensive polyps • Fungal sinusitis • Pt withc/c of • Presence of headache and complications midfacial pain • Tumor of PNS • Medically • Csf rhinorrhea compromised • Hypoplastic sinuses
  54. 54. Sinus aspiration & lavage Direct removal of bacteria laden secretions Indication: no response to medical therapy D/A
  55. 55. Maxillary needle sinusotomy  d/a  Requires force to enter anterior wall Preparation of site  Alternatives:  Mallet Infiltration of LA  Steinmann pin  Complications: Transcutaneous  Bleeding puncture ant & post to canine eminence  Infection  Dental injury  Sensory nerve disturbance  Instrument breakage
  56. 56. Caldwell luc sinusotomy By George Caldwell (1893) & Henry Luc (1897) Indications  Fungal sinusitis  Multiple antral lesions  Antrochoanal polyp  Excision of tumor  Closure of OAF  Removal of antral foreign body  Antral revision procedures  surgical approach for transantral sphenoethmoidectomy, orbital decompression
  57. 57. Caldwell luc sinusotomy
  58. 58. Caldwell luc sinusotomy Modifications Complications  Bleeding  Dental sensitivity  Infraorbital neuralgia  Osseous defect in anterolateral wall  Entrapment of inferior rectus muscle
  59. 59. FESS Coined by Kennedy Intranasal endoscopic technique that allows establishment of adequate sinus drainage without negative impact on sinus mucosa physiology and function. Principle: stop the cycle that begins with ostium blockage that leads to chronic sinusitis via stagnated secretions, tissue inflammation and bacterial
  60. 60. FESS Armamentarium
  61. 61. FESS
  62. 62. FESS Complications Intracranial hemorrhage Brain injury CSF leak Minor hemorrhage Diplopia Hyposmia Blindness Adhesions Anosmia Periorbital emphysema Epistaxis NL duct injury Meningitis
  63. 63. Sinusitis Complications:  Facial cellulitis  Orbital extension  Intracranial extension
  64. 64. Oroantral fistula Fistular canal between oral cavity and sinal mucous membrane covered with epithelium which may or may not be filled with granulation tissue or polyposis. Duration and width of lumen contributes to infection of sinus. OAC OAF(incidence: 0.3-3.8 %)
  65. 65. Oroantral fistula OAC OAF  Defect > 5mm diameter  No approximation of gingival tissues  Post op regime not followed  Loss of clot or wound dehiscence  Cyst enucleation  Smoking, drinking
  66. 66. Oroantral fistula Etiology • Iatrogenic (50%) • Presence of periapical lesions • Injudicious use of instruments • During attempted extraction • Trauma(7.5%) • Chronic infections(11%) • Malignant diseases(18.5%) • Infected maxillary dentures(3.7%) • h/o sinus surgery(7.5%)
  67. 67. Oroantral fistula Predisposing factors • Proximity of sinus floor / tuberosity • Thickened tooth cement / tooth fused to jaw bone • Infected teeth / long-standing decay • Marked periodontitis / gum disease • Lone-standing • Previous history of OAC’s.
  68. 68. Oroantral fistula Acute Chronic1. Escape of air and fluids through nose & 1.Pain, tenderness over cheeksmouth2. Epistaxis 2. Purulent discharge3. Excruciating pain 3. Post nasal drip4. Altered voice 4. Presence of polyps5. h/o surgery in vicinity of sinus 5. Generalized constitutional symptoms  Common in males,2nd-3rd decade  Immediate sign:  Displaced root /tooth  Tuberosity #
  69. 69. Oroantral fistula Diagnosis  h/o previous extraction  Valsavin test  Mouth mirror test  Cotton wisp test  Inspection  Radiological  IOPA  OPG  OM
  70. 70. Oroantral fistula Management • 3mm-5mm heals spontaneously(HANAZANE) • Ideal treatment :immediate surgery followed by Ab prophylaxis • Acute OAF: closure by simple reduction of buccal and palatal socket walls, followed by acrylic splint. • Treatment for small opening
  71. 71. Oroantral fistula1) antibiotics : Pn & derivatives2) nasal decongestants:  Ephedrine drops  Inhalations(steam,benzoin ,menthol)3) Analgesics:  Aspirin 500mg  Paracetamol 500mg  Ibuprofen 400 mg4) Antral lavage
  72. 72. Oroantral fistula Antral lavage
  73. 73. Oroantral fistula Whitehead’s varnish
  74. 74. Oroantral fistula• Acrylic plates
  75. 75. Surgical closure •Temporalis flap •Forehead flap Overview of the treatment modalities of Oro-Antral Communications Closure of Oroantral Communications:A Review of the Literature, Susan H. Visscher et al, J Oral Maxillofac Surg68:1384-1391, 2010
  76. 76. Surgical closure Factors determining flap selection  Size of communication  Timeline of diagnosing  Presence of infection
  77. 77. Buccal flap• Advantages• Disadvantages• Modifications • Moczaic • Laskin & Robinson
  78. 78. Palatal flap
  79. 79. Palatal pedicle flapA) Ito & Hara modificationB) Island flap  Gullane & Arene modification
  80. 80. Combined flap
  81. 81. Distant flaps BUCCAL FAT PAD
  82. 82. Tongue flapIntroduced by lexer,1909TechniqueAdvantagesDisadvantages
  83. 83. Grafts
  84. 84. Grafts GRAFTSAUTOGENOUS ALLOGENOUS XENOGRAFTSIliac crest Collagen sheet Porcine dermis Fibrin glue Bio guide & Bio ossChin Gold foilRetromolar area TantalumZygoma PMMA Hydroxyapatite
  85. 85. Sandwich Technique
  86. 86. Other techniques Third molar transplantation(kitagawa et al) Interseptal alveolotomy(hori et al) GTR(Waldrop & Semba) Prolamine gel(Gotzfried & Kaduk) Laser light(Janas) Splints for immunocompromised pts(llogan and coates)
  87. 87. Conclusion Due to close proximity of maxillary sinus to orbit, alveolar ridge, maxillary teeth, diseases involving these structures may produce confusing symptoms. Hence a precise information about the surgical anatomy is essential to surgeons. The oroantral fistula is a problem that requires detailed attention to the management of a flap in the mouth. For the sake of obtaining the best results and to give the patient the benefit , proper knowledge about the different types of modalities and their limitations is necessary.
  88. 88. References• ECAB: Clinical update-otorhinolaryngology-Paranasal sinuses and rhinosinusitis-V.P Sood• OMFSClinics of North America-Diagnosis & treatment of disorders of maxillary sinus-Laskin• Principles of oral and maxillofacial surgery-Peterson• Textbook of oral and maxillofacial surgery-Killey and kay• Maxillary sinus and its dental implications:dental practice handbook-Killey and Kay• Review of oral and maxillofacial surgery-Ghosh
  89. 89. References• Open access atlas of otolaryngology, head & neck operative surgery -johan fagan• Treatment of Oroantral Fistula-Klara Sokler et al, Acta Stomatol Croat, Vol. 36, br. 1, 2002• Oronasal fistula closure by tongue flap-Manimaran K et al, JIADS,Jan-mar 2011• A New Surgical Management for Oro-antral Communication,The Resorbable Guided Tissue Regeneration Membrane – Bone Substitute Sandwich Technique-C Ogunsalu, West Indian Med J 2005; 54 (4): 261
  90. 90. Thank You