Category Archives: Odontogenic Diseases of the Maxillary Sinus

RADIOGRAPHIC EXAMINATION OF MAXILLARY SINUS Radiographic examination of the. maxillary sinus may be . accomplished with a wide variety of exposures readily available in the dental office or radiology clinic.These  exposures include periapical, occlusal; and panoramic views, which will, in most instances, provide adequate information to either confirm or rule out pathologic conditions of the sinus. If additional radiographic formation is required, Waters’ radiographs (Fig. 19-3) are usual-.ly diagnostic. Rarely, linear tomography (Fig. 19-4) and computed axial tomography (Fig. 19-5) of the structures in question may be necessary. , Interpretation of radiographs of the maxillary sinus is not difficult. The findings in the normal antrum are those to be expected of a rather large, air-filled cavity rounded by bone and dental structures. The body of the sinus should appear radiolucent and should be outlined in ll peripheral areas by a well-demarcated layer of cortical bone. It is helpful to compare one side to the other when examining the radiographs. There should be no evidence of thickened mucosa on the bony walls (usually indicative of chronic sinus disease) (see Fig. 19-3), air-fluid levels (caused by accumulation of mucus, pus, or blood) (Fig. 9-6), or foreign bodies lying free. Frequently, the apices of the roots of the posterior maxillary teeth and impacted third molars may be seen to project into the, sinus floor (Fig. 19- 7). In edentulous areas the sinus may be pneuma-tized into the alveolar process and extend almost to the alveolar crest. Complete opacification of the maxillarysinus may be caused by the mucosal hypertrophy and fluid accumulation of sinusitis, by filling with lood secondaryto trauma, or by neoplasia (Fig. 19-8). isruption of the cortical outline may be a result of trauma, tumor ormation, or surgical procedures that vio-late tha sinus walls.

FIG. 19-3 Waters’ radiograph showing mucosal thickening on right maxillary sinus’floor and lateral wall. Patient had oroantral fistula secondary to removal of first molar tooth and symptoms of chronic maxillary sinusitis.

FIG. 19-4 Tomogram of midface taken in frontal plane. Large, cystlike radiolucent lesion is seen to occupy bulk of right maxillary sinus (arrows). . .

FIG. 19·5 Computed axial tomogram of head in coronal plane. Both maxillary sinusesare almost totally opacified by mucosal lesions,asis right nasopharynx. Such lesions ar~ typica.1of allergic diseaseor chronic sinusitis RADIOGRAPHIC EXAMINATION OF AXILLARY SINUS FIG. 19·6 A, Waters’ radiograph demonstrates bilateral maxillary sinus air-fluid levels (arrows). 8, Lateral radiograph demonstrates alr-fluld levels in maxillary sinus (arrow), FIG.

 

Radiographic changes are to be expected with acute maxillary sinusitis and are secondary to filling of a normal, air-containing cavity with thickened mucosal sinus lining and accumulated mucus, pus, or both. Mucosal thlckentng secondary to odontogenic infections may obstruct the ostium of the sinus and allow accumulation of mucus, which will become infected and produce pus. The characteristic radiographic changes may include an air-fluid level in the sinus (see Fig. 19-6), thickened mucosa on any or all of the sinus walls (see Fig. 19-3), or complete opacification of the sinus cavity (see Fig. 19-8). The radiographic changes indicative of chronic maxillary sinusitis include mucosal thickening! sinus opacification, and nasal or antral polyps. Air-fluid levels in the sinuses are more characteristic of acute sinus disease but

 

rent in nature, obstructive nasal disease, or allergy. It is characterized by episodes of sinus disease that respond . initially to treatment, only tb return, or that remain symptomatic in spite of treatment. Aerobic, anaerobic, or mixed bacteria may cause infections of the maxillary sinuses. The normal healthy maxillary sinus has a small population of bacteria that is composed mainly of aerobic streptococd and anaer obicgram-negative rods of the genera Porphyromonas, Prevotella, and Fusobacterium. In maxillary sinusitis of nonodontogenic origin, the causative bacteria are primarily aerobic, with a few anaerobes. The important aerobes are Streptococcus pneumoniae, Haemophilus influenzae, .and. Staphylococcus aureus. Porphyromonas, Prevotella, Peptococcus,and Fusobacterium spp. are the common anaerobes.Maxillary sinus infections of odontogenic origin are more likely to be caused by anaerobic bacteria as is theusual odontogenic infection. Rarely does H. inftuenzae or S. aureus cause odontogenic sinusitis. The predominantor ganlsrr.s are aerobic streptococci and anaerobic Peptococcus, Peptostreptococcus, orphvromonas, Prevotetla, and Eubacterium spp. . . This information is important to the selection of ariantibiotic. The otolaryngologist usually chooses a drugthat is effective against H. influenzae and S. aureus, whichis not usually necessary for odontogenic sinusitis. Drug ssuch as penicillin, erythromycin; and clindamydn are effective for sinusitis of odontogenic ongtn ..However, because of the ide.variety of microorganisms that tan be participants iIl”Cnfectionsof the maxillary sinus, it is important to ohtam purulent material for culture and sensitivity (C&S) testerting wnenever possible.Sensitivity testing may su;’gest a change to otherantibiotic if resistant organisms are cultured from the sinus and if the infection is failing to respond to appropriate initial treatment Asmany  as 25% of the organisms

cultured from acute sinus infections are beta-lactamase producers and many may be anaerobic, especially if theinfection is odontogenic in origin.

 

 

CLINICAL EXAMINATION OF MAXILLARY SINUS

Clinical examination of the patient with suspected maxillary sinus disease should include tapping of. the lateral walls of the sinus externally over. the prominence of the cheekbones and “palpation intraorally on the lateral surface of the maxilla between the canine fossa and the zygomatic buttress. The affected sinus may be markedly tender to gentle tapping or palpation. Further examination may include transillumination of the maxillary inuses. In unilateral disease, one sinus may be compared with the sinus on the opposite side. The involved sinus shows decreased transmis on of light secondary to the accumulation of fluid, debris, and pus and the thickening of the sinus mucosa.

Transillumination of the maxillary sinus is done by placing a bright flashlight or fiber optic light against the mucosa on the palatal or facial surfaces of the sinus and observing the transmission of light through the sinus in a darkened room. These simple tests help to distinguish sinus disease, which may cause pain in the upper teeth, from abscess or other pain of dental origin associated with the molar and bicuspid teeth.

EMBRYOLOGY AND ANATOMY

The maxillary sinuses are air-containing spaces that occupy the maxillary bone bilaterally. They are the first of the paranasal sinuses (e.g., maxillary, ethmoid, frontal, sphe – noid) to develop embryonically and begin as a mucosal invagination that grows laterally from the middle meatus of the nasal cavity at approximately the seventieth day of gestation. At birth the sinus cavity is still somewhat less than a centimeter in any dimension. After birth the maxillary sinus expands by pneumatization into the developing alveolar process and extends anteriorly and inferiorly from the base of the skull, dosely matching the growth rate of the maxilla and the development of the dentition. As the dentition develops, portions of the alveolar process of the maxilla, vacated by the eruption of teeth, become pneumatized. By the time a child reaches age 12 or 13, the sinus will have expanded to the point at which its floor will be on the same hortzontallevel as-the floor of the nasal cavity. Expansion of the sinus normally ceases after the eruption of the permanent teeth but will, on occasion, pneurnanze further, after the removal of one Of more posterior maxillary teeth, to occupy the residual alveolar process. The,sinus may then extend virtually to the crest of the  edentulous ridge. In adults the apices of the teeth may extend into ‘ the sinus cavity and may be identffied readily in the dry skull lying in the sinus floor. The sinuses are lined by respiratory eplthellum-a mucous-secreting, pseudostratlfied, Ciliated, columnar epithelium-and periosteum. The cilia and mucus are necessary for the drainage of the sinus, because the sinus opening, or ostium” Is not In a dependent position but lies two thirds the distance up from the inferior part of the medial wall and drains Into the nasal cavity. The maxillary sinus opens into the posterior, or inferior, end of the semilunar hiatus, which lles In the middle meatus of the nasal cavity,’between the inferior and middle nasal conchae, The ostium remains at the level of the original lateral extension from the nasal cavity from which the sinus began formation in the embryo and the location of which is close to the roof of the sinus (Fig. 19-1). Beating of the cilia moves the mucus produced by the lining epithelium and any foreign material contained within the “Sinus toward the ostium, from which it drains Intothe nasal cavlty.

The maxillary sinus is the largest of the paranasal sinuses. it may be described as a four-sided pyramid, with the base lying vertically on the medial surface and forming the lateral nasal wall. The apex extends laterally into the zygomatic process of the maxilla. The upper wall, or roof, of .the sinus is also the floor of the orbit. The posterior wall extends the length of the maxilla and dips into the maxillary tuberosity. Anteriorly and laterally the’ sinus extends to the region of the first bicuspid or cuspid teeth. The floor of the sinus forms the base of the alveolar process. The adult maxillary sinus averages 34 mm in anteroposterior  direction: 33 mm in height, and 23 mm in .width. Its volume is approximately 15 cc (Fig. 19-2).

Odontogenic Diseases of the Maxillary Sinus

CHAPTER OUTLINE

EMBRYOLOGY AND ANATOMY
CUNICAL EXAMINATION OF MAXILLARY SINUS
RADIOGRAPHIC EXAMINATION OF MAXILLARY SINUS ,
ODONTOGENIC INFECTIONS OF MAXILLARY SINUS
TREATMENT OF MAXILLARY SINUSITIS
COMPLICATIONS OF SURGERY INVOLVING MAXILLARY
SINUS
MUCOUS-RETENTION PHENOMENON
OROANTRAL COMMUNICATIONS
Immediate Treatment
, Treatment of Long-Standing Communications