MAXILLARY SINUS

1. Oroantral Fistula

2. Contents
Introdction
Definition
Symptoms
Investigations
Management of
Early cases
Delayed cases
Conclusion
Reference

3. Introduction
•Oroantral perforation is an unnatural communication
between oral cavity & maxillary sinus.
•It may occur due to several causes like extraction of
tooth,surgery of maxillary sinus.
•Persistence of fistula results in various problems like
entry of food into antrum.
•Early signals are seen when bloodclot gets
disintegrated.
Correct management can avoid further complications

5. .
Definition
1)An oroantral perforation is an unilateral
communication between the oral cavity & maxillary
sinus.
2)An oroantral fistula is an epithelialized
pathological communication between these 2
cavities.

6. Symptoms
a)Fresh oroantral communication :
Escape of fluids
Epistaxis
Escape of air
Enhanced column of air
Excruciating pain

7. b)In late stage :
Pain
Persistent,purulent/mucopurulent,foul unilateral nasal
discharge
Post nasal drip
Possible sequelae of general systemic toxaemic
condition
Popping out of an antral polyp.

8. Investigations
1)Probing
2)Nose blowing test
Cotton wisp kept near fistulous opening & patient
asked to blow the nose with closed nostrils and open
mouth.If there is oroantral communication,air
passes and displaces the cotton wisp.
.

9. 3)Mouth mirror test – Patient is made to
perform valsalva manoeuvre with a mouth mirror
placed facing oral opening of fistula.If the mirror
get fogged,it indicate presence of oroantral
communication

10. 4)Suction test :
Suction nozzle when placed over the fistula will
create a sound similar to that produced by an empty
bottle when it is blown.This sound can’t be heard when
the sinus is chronically infected.
5)When the patient asked to hold fluid within the
mouth,fluid can be seen escaping through the nose.

11. Management
Objectives:
To protect sinus from oral microbial flora
To prevent escape of fluids & other contents across
communication
To eliminate existing antral pathology
To establish drainage through inferior meatus

12. Ideal treatments :
Immediate surgery repair to achieve primary closure.
Simultaneous antibiotic prophylaxis to prevent sinus
infection.
Immediate primary closure is done by simple
reduction of buccal& palatal socket walls &
approximate buccal & palatal flaps to close the defect.
Acrylic denture can be use to provide barrier to
indvertment entry of food particles.
Treatment of early cases

14. Ideal circumstances :
If a patient is under GA ,a surgical procedure can
carried out in operation theatre a tooth or a root can
be easily removed from the antrum via the orifice ;
even if procedure would entail a slight enlargement of
orifice
While the similar is to be performed under a LA in a
dental chair it is not advisable to explore the antrum
for recovery of tooth or root.

15. Various procedures that can be employed are :
Complete closure of socket by approximation of
buccal& palatal gingival margins.
Additional procedures like:
Reduction in the height of underlying alveolar bone
Relieving incisions in adjacent tissues
Referral of patient to an oral & maxillofacial surgeon

16. Post operative care
1) Patient should instructed to avoid
blowing her/his nose.
2)Antibiotics :
Penicillins can be started with IV route & later
switched over to oral route.
Penicillin V 250-500 mg ,q.i.d
If organism is resistent to penicillin,broad
spectrum antibiotic is prescribed.

17. 3)Nasal decongestants :
The term applies Vasoconstrictor nasal drops &
sprays & inhalations.
Encourage drainage of pus & secretions.
Preparations include :
Ephedrine nasal drops,0.5% instilled intranasally
every 2-3 hours.
Steam inhalations – helps in thinning down the
mucous.
Benzoin & menthol inhalations.

18. 4)Analgesics
Aspirin - 500mg,q.i.d
Paracetamol - 500mg,t.i.d
Ibuprofen - 400mg,t.i.d

19. Temporary therapeutic measures before
surgical closure:
1)Whitehead’s varnish pack
•Pack - A strip gauze / ribbon gauze is used to pack over
the socket & secured with sutures.
•Superficially pack is supported by mattress suture.
2)Denture plate:
To provide barrier to prevent entry of food particles
into the antrum

20. Whitehead’s varnish
Benzoin : 10 parts : 44g
Iodoform : 10 parts : 44g
Storax : 7.5 parts : 33g
Balsam of tolu : 5 parts : 22g
 Solvent : ether to 1 fl oz or 100 parts

21. Treatment of delayed cases
•Include treatment of cases seen more than 24
hours after accident
•If there is purulent discharge from fistula the
patient develops signs of acute / chronic
sinusitis ; then the maxillary sinus should be
gently irrigated with warm normal saline.

22. Treatment of oroantral fistula
of long duration (>a month)
•Here fistulous tract is usually well epithiliazed
•Surgical closure is required.
•patient presents 2-3 weeks after extraction
•Complain of foul taste in the mouth
•Discharge from fistula into the mouth.

23. Management
•Drainage of maxillary sinus is established through the
fistula by enlarging it surgically .
•The sinus should be gently irrigated with normal saline
until it is clear.
•Surgical procedures used in closure of oroantral fistula
can be divided accordingly to type flap used into:
•Palatal flap
•Buccal flap
•Combination of both

24. Essential features
Free end of the flap should have adequate blood
supply
 Buccal flap designed that base should be wider than
the apex to ensure adequate blood supply at apex.
Palatal flap should be so that grater palatine vessels
are incorporated in the transposed tissues.
 Suture line is well supported by sound bone.

25. Mobilisation of either buccal / palatal flap
should be done in such a manner that there is no
tension on the suture line.
Buccal flap advancement operation:
•Described by Von Rehrman
•Based on principle of periosteal release
described by Berger

26. Procedure
1)Injection of LA in the mucobuccal fold.
It reduces capillary bleeding (vasoconstriction) &
chance of post operative haematoma.
2)Excision of fistulous tract:
Incision made around fistulous tract 3-4 mm marginal
to the orifice,as the soft tissue aperture is always
smaller than the diameter of bony defect.
3)2 divergent incisions are taken with blade number
15,from each side of orifice into buccal sulcus for a
distance of 2.5 cm

28. Incision made down till the bone
Mucoperiosteal flap reflected carefully
4)Advancement of buccal flap:
When buccal mucoperiosteal flap fully short of
covering the fistula ,flap can be advanced
A horizontal incision is made in the periosteum ,as
high as the possible which allows advancement of
buccal flap.
5)Inspection of maxillary sinus:
For evidence of infection either through fistula /
by illumination

29. 6)Arrest of haemorrhage to avoid haematoma
7)Closure of wound
Mucoperiosteal flap sutured into position
across fistula with interrupted sutures
8)Post operative medications –antibiotics
analgesics and nasal decongestants
9)Restriction to soft diet
10)Instructions to patients
To avoid sneezing
To explore wound with tongue

30. 11)To avoid nasal blowing in early stages
It creates back pressure on the sutures before
consolidation is complete.
Causes surgical emphysema through mucoperiosteal
flap into soft tissue of cheek
12)Removal of sutures 7-10 days post operatively
13)Review

31. Performed to facilitate drainage the conclusion of
an operation performed to close an oroantral fistula
to remove a tooth/ root from the sinus.
Drawbacks :
It can’t drain the sinus satisfactorily as the point
of drainage is not at point of dependent drainage,as
the antral floor is 1.5 cm below nasal floor.
It interfere the ciliary pathways.
Intranasal antrostomy

32. Surgical procedures
Small sized osteotome pushed through inferior meatus
the nostril
in the nasal cavity into the maxillary sinus
A big curved artery forceps is passed through the
opening and an iodoform impregnated ribbon gauge
pack’s end is grasped into it’s beak and pulled out into
An antrostomy can be performed by removing
1cm of medial wall of antrum which bulges into the
sinus below the level of inferior turbinate.It
should extend to the floor of the nose.

33. Nasal mucosa incised from the antral surface on 3
sides and nasal flap the created is reflected into
antrum.
Palatal predicted flap:Rotational advancement
flap operation :
 Ashley in 1939 devised the palatal flap
operation,where a palatal flap is rotated across
fistula so that suture line rests on sound bone on
buccal side of orifice.
 Abundant blood supply in palatal tissue promotes
satisfactory healing.

34. Procedure involving palatal flaps don’t affect
buccal vestibular height.
 Palatal rotational advancement flap provides
adequate mobility & tissue bulk to the flap.
Kruguer suggested a V shaped excision of lesser
curvature of flap to minimize folding.

35. Ashley’s operation
Local anaesthesia – to reduce bleeding.
Excision of fistulous tract.
Incision around fistula about 2mm away from
epithelialized edge
Marking out of proposed palatal flap-done with
Bonney’s blue ink before operation
Raising a palatal mucoperiosteal flap.
Maxillary sinus inspected & cleared of polyps &
irrigated with normal saline.

36. Trimming of buccal mucoperiosteum.
Rotational advancement of palatal predicted flap to
approximate buccal margin with interrupted sutures

37. Combination of buccal & palatal
flaps:
To close larger defects.
Mobilization of both palatal &buccal flaps helps
to have 2 layered closure.
Used only if earlier repair is a failure.
Double layered closure not only improves the
strength of flaps but also minimize contraction &
risk of infection

38. Caldwell –Luc operation
George Caldwell in 1893 described a method of
gaining entry into the maxillary sinus
via canine fossa with nasal antrostomy.
Henri Luc in 1897 reported the same procedure as
his own
Indications
To treat chronic maxillary sinusitis
Removal of cysts or benign growths from the maxillary sinus
Removal of impacted canine or 3rd molar
Removal of root fragments ,teeth or foreign body from
the maxillary sinus
Management of haematoma in the maxillary sinus

39. Procedure :
1. LA/GA (preferred
)given.
2.semilunar incision
is planned in the
buccal vestibule
from canine to 2nd
molar area just
above the gingival
attachment.

40. 3. Mucoperiosteal flap is elevated with periosteal
elevator till the infra orbital ridge.
4. An opening created in the anterior wall of maxillary
sinus with chisles / dental drills.

41. •Opening enlarges in all directions with Rongeur
forceps to permit the inspection of sinus cavity.
5.Pus should be sucked away from the sinus & a
thorough irrigation of maxillary sinus is carried
out with copious saline wash.
6.Inspection of maxillary sinus.
7.Thickened infected maxillary sinus can be
elevated with Howarths periosteal elevator &
removed & seat for histopathological examination

42. 8.If there is profuse bleeding sinus can be packed
with ribbon gauze socked in adrenaline 1:1000 for 1-2
min.
9.Antral cavity again is irrigated & can be packed
with iodoform ribbon gauze.
10.Incision closed with 3.0 silk
11.postoperative management
12.Pack removal on 5th day.

43. Conclusion
•Oroantral fistula is a communication between the
oral & nasal cavities.
•Periapical lesions osteomyelitis extraction…can
cause oroantral fistula.
•Symptoms include pain nasal discharge , postnasal
drip.
•Oroantral fistula can be confirmed by nose blowing
test.
•Immediate surgery followed by antibiotic prophy-
axis is the ideal treatment.

44. •Supportive measures includes antibiotics nasal
decongertants analgesics
•Surgical procedures procedures can be using buccal
/ palatal / both flap usage.
•Buccal flap operation introduced by Von rehrmann.
•Intranasal antrosomy using palatal flap introduced
by Ashley.
•Caldwell – luc operation is gaining entry into the
maxillary sinus via canine fosay with the nasal
antrostomy.

45. Reference
1)Textbook of oral & maxillofacial surgery by
Neelima Anil Malik 2nd edition
2)Textbook of Oral & Maxillofacial Surgery
by S.M.Balaji,2nd edition