Maxillary sinus disorders can be inflammatory, cystic, traumatic, or tumorous in nature. Common inflammatory disorders include sinusitis, mucositis, antral polyps, and antroliths. Sinusitis can be acute, subacute, or chronic depending on duration. Chronic sinusitis may develop from acute sinusitis that fails to resolve. Fungal sinusitis can occur in immunocompromised individuals. Traumatic disorders include oroantral fistulas resulting from tooth extractions or facial trauma. Precise diagnosis involves medical history, clinical examination, and radiographic imaging such as panoramic x-rays or CT scans. Treatment depends on the specific disorder but may include antibiotics, surgery, or antral irrigation

1. DISORDERS OF MAXILLARY SINUS
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education

2. INDEX
• INTRODUCTION
• DEVLOPMENT AND GROWTH
• ANATOMY
• APPLIED SURGICAL ANATOMY
• MICROSCOPIC FEATURES
• FUNCTIONS OF MAXILLARY SINUS
• DIAGNOSTIC EVALUATION
• DISORDERS OF MAXILLARY SINUS

3. CLASSIFICATION
Inflammatory
Cyst of the
maxillary sinus
Traumatic
diseases
Tumors of
max.sinus
Other diseases
involving
max.sinus
Developmental

4. DISORDERS OF MAXILLARY SINUS
1.Developmental anomalies
-Agenesis
-Aplasia
-Hypoplasia
-Supernumerary maxillary sinus
2. Inflammatory diseases
-Mucositis
-Maxillary sinusitis
-Empyema
-Antral polyps
-Antroliths

5. . 3.Cysts of the maxillary sinus
- Odontogenic cysts
- Non odontogenic cysts
4. Traumatic diseases
-Oro-antral fistula
-Root or foreign body in antrum
-Fractures
-Pneumocele and cheek emphysema

6. 5. Tumors of the maxillary sinus
-Benign tumors -Antral Papilloma, Osteoma,
Odontomes, Odontogenic
tumors, Cholesteatoma
-Malignant tumors- Squamous cell carcinoma,
adenocarcinoma, metastatic
carcinoma
6. Other diseases involving the maxillary sinus
-Fibro-osseous diseases,
-Granulomatous diseases

7. INFLAMMATORY DISEASES OF MAXILLARY SINUS
• Inflammation may result from a variety of causes
such as infection, chemical irritation, allergies and
introduction of a foreign body, or facial trauma.
• Viral infection may not cause any radiographic
change in the sinus.

8. 1) Mucositis
2) Maxillary sinusitis
3) Empyema
4) Antral Polyp
5) Antroliths

9. MUCOSITIS
• The mucosal lining of the paranasal sinuses is
normally about 1 mm thick. When inflamed, it may
increase by 10 to 15 times.
• This inflammatory change may be referred to as
mucositis. Mucosal thicknening greater than 3 mm
is most likely pathologic.
• Causes: infection, allergy, chemical irriatation,
foreign body, trauma

10. Thickened sinus mucosa
• Clinical Features
It is usually asymptomatic, and is discovered on
routine radiograph.
• Radiographic Features:
The image of thickened mucosa is
readily detectable in the radiograph as a non corticated
band noticeably more radiopaque than the air filled
sinus, an paralleling the bony wall of the sinus.
• Treatment
As the condition is asymptomatic treatment is not
required.

11. SINUSITIS
• Sinusitis is a condition involving inflammation of
the paranasal sinus mucosa.
• The term is usually restricted to conditions that
are primarily inflammatory, cause subjective
symptoms and persist longer than 7 days.

12. • Types:
1. Acute- conditions present for less than 2
weeks.
2. Subacute- Conditions present from 2
weeks to 3 months.
3. Chronic - Condition present for more
than 3 months.

13. ETIOLOGY
• Sinusitis is usually caused by blockage of
drainage from the osteomeatal complex,
• This leads to ciliary dysfunction and retention of
the mucosal secretions, followed by bacterial
invasion and overgrowth
• The triad includes - Nasal congestion,
Pathological secretion and Headache.

14. The organisms thought to be responsible are ;
• In acute sinusitis: Streptococous pneumoniae,
Hemophillus influenzae and Moraxella catarrhalis.
• In chronic sinusitis: bacterial flora become
polymicrobial. And addition to above anaerobes
and microaerobic streptococci, staphylococci and
even gram –ve organisms.

15. DENTAL CAUSES
• Periapical infection from the teeth- upper
molars & premolars
• Oroantral fistula
• Periodontitis
• Dental material in antrum/ foreign bodies
• Implants
• Infected dental cyst

16. NONDENTAL CAUSES
 Mechanical obstruction of the ostium
 Common cold
 Allergic rhinitis
 Deviated nasal septum, nasal polyp, prolonged nasotracheal intubation
Direct bacterial contamination
Foreign bodies in sinuses
Immune deficiency
Cysts or tumors of maxillary sinus
Congenitally abnormal clearance mechanisms.

17. The vicious circle of inflammation
•
• FROM : Mackey and cole(1987)
Failure to eliminate
“ATTACKER”
Amplified
inflammation
Progressive
damage to
“BYSTANDER”
normal issue
Impaired
mucociliary
clearence
Release of
colionihibitory factors
Microbial
colonizati
on

18. CLINICAL FEATURES
• Severe pain located in the cheek and posterior maxillary
teeth, nasal blockage.
• Purulent rhinorrhea and noctural posterior nasal drip
• Pain may be exacerbated by stooping or lowering the head.
• The pain is often increased by biting on the affected side but
unaffected by drinking hot, cold or sweet fluid.

19. • A history of bloody discharge may represent an acute infection of an
underlying malignant lesion.
• Anosmia - Loss of smell sensation.
• Foul discharge.
• Facial asymmetry - Due to swelling on involved side, tenderness to
pressure
• Posterior teeth are sensitive to percussion.
• General Symptoms- Fever ,malaise, chills, and an elevated leucocytes
count

20. EXAMINATION
• Asymmetrical swelling and erythema of cheeks should be assessed.
• Thumb pressure on cheeks to elicit tenderness extraorally and can also be
done intraorally by finger palpation in buccal sulcus in premolar and molar
region.
• For proper examination of nasal passage nasal speculum and headlight are
used to see reddening and inflammation and there may be even pus
present in nasal mucosa of anterior nares.

21. • Gentle percussion of maxillary teeth with a mirror handle may elicit
tenderness of one or more teeth suggest a dental cause but tenderness of
a whole buccal segment is indicative of sinusitis.
• One should look for caries, mobility, fractured tooth, faulty restoration,
etc,. to rule out dental cause.

22. DIFFERENTIAL DIAGNOSIS
 Dental or sinus disease
 Psychogenic facial pain
 Neuralgic pain
 TMJ disorder
 Traumatic injuries

23. INVESTIGATIONS AND DIAGNOSIS
• Water's projection is the radiograph of choice. It shows both
the sinuses therefore allows comparison of the two sides and
correlation with the symptoms.
• Periapical, occlusal or panoramic views may be of use in
identifying the dental cause in acute sinusitis.

24. Radiographic features
Following patterns are seen
1. Localized thickening at base of sinus
2. Roughly generalized thickening of sinus walls
3. Complete opacification of sinus.

25. • In cases of allergy, mucosa will be more lobulated in contrast to
that in infection when it is straighter and parallel to sinus wall.
• Resolution of acute sinusitis will be apparent as small clear areas
appear
• Chronic sinusitis may result in persistent opacification of sinus
and sclerosis or thickening of surrounding bone

26.  Plain film examination is accurate in detecting the maxillary
sinus opacification. Radiographic hallmark of acute sinusitis
is an air-fluid level.
 CT scan demonstrates mucosal abnormalities in the nose and
sinuses very clearly.

27.  Aspiration of fluid from the sinus- antral puncture via the inferior
meatus or canine fossa is done for bacteriological culture and
sensitivity.
 Sinus Endoscopy -Direct visualization of the sinus mucosa by
antroscopy through the canine fossa will confirm the diagnosis

28. TREATMENT
• Removal of cause of dental infection- Drainage of pus from root
canal or extraction
• Use of decongestant nasal drops - Ephedrine nasal drops (0.5%, 8
hourly ) are commonly used and can give relief for several hours.
• Xylometazoline (0.1 %) is an alternative to ephedrine (8 hourly in
head down position to prevent the fluid running straight into the
pharynx)

29. THE HEAD DOWN AND FORWARD POSITION FOR NASAL DROP INSTILLATION

30.  Use of antibiotics - Effective regimen includes Doxycycline hydrochloride 100
mg daily following a loading dose of 200 mg. Amoxicillin is also effective.
 Analgesic and anti-inflammatory drugs (NSAID)
 Steam inhalation – acts by hydrating the mucous blanket, making it less
viscous and encouraging normal ciliary clearance.
Volatile aromatic additives like menthol and
eucalyptus are suitable agents can be used.

31. • Antral lavage –
If antibiotics and nasal drops fails to resolve the
condition, pus must be removed from the sinus by antral lavage, which
may need to be repeated several times on a weekly basis until clear fluid
rather than pus is retrieved in the washings.
Surgical management of recurrent acute sinusitis
includes inferior meatal antrostomy

32. COMPLICATIONS OF ACUTE SINUSITIS
• Spread of infection to the orbit often by way of associated
ethmoidal sinus may cause orbital swelling, pain and loss of
vision.

33. • PA paranasal sinus radiograph: In the right maxillary sinus an air-fluid level can be
recognized (arrow), which proves acute sinusitis. The air content of the left
maxillary sinus is decreased due to mucosal swelling (double arrow).

34. CHRONIC SINUSITIS
• Chronic maxillary sinusitis is a squeal of an acute infection that fails to resolve by three
months.
• Etiology
• It may be due to persistence of external aggravating factors such as nasalpolyposis, septal
deviation, allergic rhinitis and even chronic marginal Periodontitis.
• Chronic sinusitis is often associated with allergic rhinitis, asthma, cystic fibrosis and
dental infection.
• A dental cause accounts for 40% of cases of chronic maxillary sinusitis.

35. SIGNS AND SYMPTOMS
• This is based on history of repeated boutes of acute infection
or persistent inflammation, clinical features, sinus
radiographs and sinoscopy.
• Radiograph Shows–
Persistent opacification of sinus, sclerosis and thickening of
the surrounding bone

36. TREATMENT
• Removal of local factors such as dental cause, ostium blockage.
• Inferior meatal antrostomy
• Antral lavage
• Cald-well-Luc Surgery
• Transnasal endoscopic surgery -This reveals the presence of bony distortions, nasal
mucosal thickening or polyps & source of discharge of pus.
So, based on the diagnosis, corrective surgery and access for drainage of sinuses
can be achieved

37. COMPLICATIONS OF SINUSITIS
• Inflammatory polyps
• Empyema
• Mucous Retention Cyst - is sequel of an
inflamed hyperplastic mucosa.
• Mucocele
• Mucopyocele

38. FUNGAL SINUSITIS
 Mucormycosis, Histoplasmosis and candidiasis. The
most common fungal infection that involve the
maxillary sinus are Aspergillosis,
rhinoscleroma,Blastomycosis,mucormycosis.
 The most common fungal pathogen of the PNS in
AIDS is Aspergillus
 Fungal sinusitis can be divided into three categories-
 Fungal ball
 Chronic erosive
 Allergic Fungal sinusitis.

40. • Healthy individuals have a localized lesion and patients with
debilitated illness are susceptible to generalized lesions. The use of
antibiotics, predisposing factors such as diabetes, tumors and
reduced physical resistance are associated with aspergillosis
• Mucormycosis - It is reported in immunocompromised patients
and is potentially lethal.
• It occurs in two forms- Superficial and Visceral

41. Signs and Symptoms –
• Bloody nasal discharge
• Necrosis of nasal turbinate
• Ptosis and proptosis
• Opthalmoplegia
• Loss of vision
• Trigeminal anasthetia
• Facial palsy.

42. • Radiographic Features are usually nonspecific.
• Radiographic features may be opacification of a
maxillary sinus and sclerotic bony reaction.
• Small round foreign body of high radiodensity
(higher than bone or dental enamel) suspended
in antrum.
• Air fluid levels are uncommon and if present
suggest bacterial superinfection

43. • The radiologic finding of aspergillosis of the
maxillary sinus is generally characterized by
metallic dense shadows resembling foreign
bodies. This phenomenon is due to local
deposition of calcium phosphate in the center
of fungal masses

44. TREATMENT
• Control of underlying predisposing factors.
• Surgical excision of lesion
• Antibiotic therapy – Amphotericin B is a drug of
choice. Irrigation of the maxillary sinus through the
ostium with amphotericin B solution for a week to
months
• Treatment of the solitary fungal sinusitis consists of
removal of mycotic tissue by exploration of the sinus
and fistulectomy under local anesthetia.

45. Maxillary Sinusitis in Children
• Both acute and chronic sinusitis are less common in
children than in adults because of less unfavourable
gravitational drainage site.
• The deciduous teeth are separated from the sinus
by the permanent tooth germs and are therefore less
likely to cause infection. But they do occur and with
potentially very serious consequences

46. EMPYEMA
If sinus ostium remains blocked, an empyema
is possible, which is ‘cavity filled with pus’
Radiographically sinus will appear completely
opaque
Decalcification of surrounding bony walls and
haziness of trabecular bone next to the sinus
wall is seen
It may extend into the adjacent bone with
development of osteomyelitis

47. ANTRAL POLYP
• The thickened mucosa of a chronically inflamed sinus frequently forms
into irregular folds called polyps.
• Polypoid hypertrophy of the mucosa may develop in an isolated area or a
number of areas throughout the sinus.
• Etiology –
• Antral polyps are secondary to allergy, or infection

48. • Clinical Features –
Polyps may cause bone displacement or destruction. Polyps in the maxillary sinus can displace or
destroy the medial or lateral walls of sinus. Unilateral proptosis may develop.
• Radiographic Features –
Radiographic image of bone destruction associated with a thickned mucosal lining
when the polyps are extensive and associated with sinus obstruction the term sinonasal
polyposis is used.

50. ANTROLITHS
• The term "maxillary antrolith" was introduced by
Bowerman in1969.
• Antroliths occur within the maxillary sinuses and are
the result of deposition of mineral salts around a nidus,
which may be introduced into the sinus extrinsically
(false) or could be intrinsic (true), such as masses of
stagnant mucous in sites of previous inflammation.

51. CLINICAL FEATURE
• The smaller antroliths are asymptomatic and usually
are discovered as incidental findings on radiographic
examination.
In larger antroliths, patients may experience an
associated sinusitis, blood stained nasal discharge &
nasal obstruction

52. RADIOGRAPHIC FEATURES
• Antroliths can be seen in periapical, occlusal or panoramic radiographs.
• Antroliths are well defined radiopaque lesions and may have smooth or
irregular shape.
• The internal density may be homogenous or heterogeneous and in some
instances, of radiolucency and radiopacity in the form of laminations may
be seen.

53. DIFFERIATIAL DIAGNOSIS
 Root fragments in the sinus- In root fragments history of patient and
presence of pulp canal helps to differentiate.
 Rhinolith- Rhinoliths are found within the nasal fossa. A posteroanterior
skull view helps to identify the location of a rhinolith
 Odontoma
 Osteoma

54. TREATMENT
• Removal of symptomatic antrolith

55. TRAUMATIC DISEASES OF THE MAXILLARYSINUS
ORO ANTRAL FISTULA
 Oroantral fistula is an abnormal communication
between the oral cavity and the maxillary sinus.
It can result due to several causes such as
extraction of teeth, massive trauma, surgery to
maxillary sinus, osteomyelitis of maxilla, malignant
tumor, infected upper implant denture, Malignant
granuloma

56. CLINICAL FEATURES
Immediate symptoms:
 Regurgitation of liquids from the mouth into the nose.
 Unilateral epistaxis due to blood in maxillary sinus
escaping through the nasal ostium.
 Escape of air from the mouth into the nose and an
alteration in vocal resonance.
 An inability to blow out the cheeks and smoke
cigarettes

57. Delayed symptoms:
 Unilateral mal odorous nasal discharge (Purulent or
mucopurulent).
 Postnasal mucus drip will often lead to an unpleasant
taste accompanied by nocturnal cough, horseness,
earache, facial pain or headache
 Sometimes patient experiences painless lump at the
extraction socket.
 Inability to 'draw' on a cigarette or pipe, or inability
blow a wind instrument.

58. Signs of Recently created OAF-
 After forceful extraction, floor of sinus seen with
root of the teeth
 Sudden disappearance of upper molar root while
extraction
 There may be water running out of the nose while
rinsing

59. TEST TO ESTABLISH THE PRESENCE OF RECENTLY CREATED OAF
 If the fistula is large it will be obvious on simple inspection but if
patency of OAF remains in doubt, nose blowing test may be
confirmatory.
 Compression of anterior nares followed by gently blowing down
the nose (with mouth open) causes a rise in intra-oral pressure,
exhibited by whistling sound, escaping air bubbles, blood or pus may
appear at the oral orifice.
 There may be alterations in resonance of the patients voice
immediately after the extraction

60. Established fistula:
 A simple dimple on the alveolar ridge
 Invasion of antral polyp through fistula resulting
in sudden appearance of exophytic mass on
alveolar crest
 Aspiration of air into mouth through tooth socket
 Tenderness positive over maxillary sinus

61. DIFFERENTIAL DIAGNOSIS
 Sinus tract from a chronic alveolar abscess- A radiograph
taken with a gutta percha cone placed in the tract will yield
differential information
 Osteomyelitis in the area
 Malignancy - Openings in the maxillary antral floor that
have been produced by malignant disease are often
accompanied by irregular bony margins due to erosion by
tumor

62. Radiograph may show break in continuity of
floor of maxillary sinus

63. MANAGEMENT OF OAF
• Repair as soon as possible- Closure within the
first 48 hours reduces the chances of infection
and the development of chronic changes in
the antral mucosa and is associated with
faster healing and a higher success rate.

64.  Treatment of OAF, seen within 24 hours of accident – Edges
of the wound should be closed immediately after which the
nasal drops, inhalation and antibiotics are given.
 If opening is small, great care is to be exercised such as
avoidance of use of irrigation, vigorous mouth washing and
forceful nose blowing
 In majority of cases good clot will form and normal healing
will occur

65. Treatment of OAF Seen more than 24 hours:
 soft tissue margins of fistula are infected.
 Allow the edges of wound to heal soundly for 3
weeks.
 First antibiotics, analgesics and decongestants
should be prescribed and then after healing
surgical repair is done

66.  Treatment of OAF which has been present for more than
one month-
 In this fistulous tract is well epithelized so healing is difficult.
Drainage of maxillary sinus should be established through
fistula by enlarging it surgically and sinus should be gently
irrigated daily with normal saline until the washings are
clear.
 In some cases antral lavage and antrostomy can be done to
help drainage

67. Surgical procedures used for the closure of OAF
–
Rehrmann’s buccal flap operation
Intranasal antrostomy
Ashley’s palatal flap operation

68. ROOT OR FOREIGNBODY IN THE ANTRUM
• The inadvertent displacement of a root, even a whole tooth into the
maxillary sinus may cause an oro antral fistula.
• Following incomplete extraction of a tooth the apical segment
remaining in the socket may be dislodged by injudicious use of
elevators into the sinus.
• Various foreign bodies have been reported in the maxillary sinus.
Most of them gain entry via OAF and others gain entry through a
tooth-socket, during an operation in proximity to the antrum

69. Foreign bodies can be
• Burs,
• Dental impression material,
• RC filling material,
• Implants.
• Matchsticks, Bullets, missile fragments
etc.

70. Clinical features:
• Some of these objects may remains
asymptomatic, others may result in chronic
sinusitis.

71. INVESTIGATIONS ANDDIAGNOSIS
• Careful examination of Periapical or occlusal
radiographs - show a root within the sinus or
• Break in continuity of floor of antrum shows
point of entry.
• A panoramic radiograph & water's view are
also important.

72. A root tip in the sinus does not have lamina dura
around it

73. ECTOPIC
ERUPTION OF
MAXILLARY 3RD
MOLAR

75. MANAGEMENT
• The radiographs may show separated nasofrontal, maxillofrontal,
zygomaticofrontal and zygomaticotemporal sutures.
• The nasal bones, frontal processes of the maxilla, orbital floors and
pterygoid plates may show radiolucent lines and discontinuity.
• Associated fracture of the walls of the maxillary sinuses result in a
radiopaque radiographic appearance due to filling of blood.

76. CONCLUSION
• After Highmore delievered the first scientific description of the maxillary
sinus in 1651,countless authors have tried to explain the significance of
the paranasal sinuses.
• There is still considerable interest in these structures, mainly because of
their relation to different diseases, the biological role of paranasal sinuses
remain obscure

77. • Because of the close proximity of the maxillary teeth with the maxillary
sinuses, these are the most important paranasal sinuses in dental point of
view.
• Special care during surgical procedure prevent OAF , and proper antibiotic
coverage may save the patients from lethal complication from several fungal
infections inv. Maxillary sinus.

78. REFERENCES
• GRAY’S ANATOMY,39TH EDITION
• CLINICALLY ORIENTED ANATOMY,MOORE & DALLEY,5TH EDITION
• MAXILLARY SINUS &IT’S DENTAL APPLICATIONS- David. A. Mcgowan
• TEXTBOOK OF ORAL SURGERY-NILIMA MALIK
• KRENNMAIR GERALD: MAXILLARY SINUS ASPERGILLOSIS-JOURNEL
OF ORAL AND MAXILLOFACIAL SURGERY. 1995;53:657-663

79. THANK YOU

80. FRACTURES
Fractures of the maxillary sinus includes
• Fractured tuberosity
• Zygomatic Complex fracture
• Le Fort I fracture
• Le Fort II fracture
• Le Fort III fracture
• Orbital floor blowout fracture.

81. • Fractures that involve maxillary sinus may be
classified as a single (isolated) wall fracture, as
a part of a complex fracture or as a
component of a trans facial fracture .

82. FRACTURED TUBEROSITY
• This occurs most frequently when extracting a lone standing upper
third molar
• Fracture should be immobilized to promote healing by splint, if the
teeth are present in opposing arch.
• Fractures are allowed to heal and then tooth is removed in sections
by bur.
• The tuberosity should be retained as it helps in denture retention.
• Antibiotics, nasal drops and inhalation are prescribed to prevent
chronic OAF.

83. MIDFACE FRACTURES
• The radiographs may show separated nasofrontal,
maxillofrontal, zygomaticofrontal and zygomaticotemporal
sutures.
• The nasal bones, frontal processes of the maxilla, orbital
floors and pterygoid plates may show radiolucent lines and
discontinuity.
• Associated fracture of the walls of the maxillary sinuses result
in a radiopaque radiographic appearance due to filling of
blood.

84. • Complications of fractures -
chronic inflammatory mucosal changes can
occur in the maxillary sinus following fractures

85. ORBITAL FLOOR BLOW OUT FRACTURES
• Due to impact of external object, the rapid
increase in intraorbital pressure is transmitted
to the orbital walls and fracture occurs at the
thinnest parts of the orbital floor called orbital
blow out fracture

86.  “Hanging drop appearance” due to
herniation of periorbital fat and
extravasated blood from ruptured
periosteum into the maxillary sinus
 Radioopacity in the antrum
 Maxillary sinus Endoscopy - may be
used for diagnosis of orbital floor
fractures

88. • A and B, Drawings in lateral (A) and frontal (B) projections
• show Le Fort I fracture runs horizontally above maxillary alveolar process.
Pterygoid plates are broken, as is true in all types of Le Fort fracture. Walls of
maxillary sinuses in this plane are broken, including point at anterolateral margin
of nasal fossa. Maxillary teeth would be movable on physical examination relative
to remainder of face.