Oroantral Communication and its management

1. Jibesh Munankarmi
BDS Final year
Department of Oral
and Maxillofacial
Surgery

2.  Introduction
 Definition
 Etiology
 Symptoms
 Diagnosis
 Management
 References

3.  The maxillary sinus is the pneumatic space that is lodged inside the
body of maxilla and that communicates with the environment by the
way of middle nasal meatus and nasal vestibul -Orban`s

4. It is also known as Antrum of highmore.
They are two in number, one on either side of the maxilla,
and they are the largest of paranasal air sinuses.
It can be described as pyramidal in shape, consisting of a
base, an apex and four sides.
Base: lateral wall of the nose
Apex: projects laterally into zygomatic process of maxilla
Four walls are formed by:
1. The roof of antrum or the floor of orbit
2. The anterior
3. Infratemporal surface of body of maxilla
4. The alveolar process of maxilla which is the floor of the
sinus

5. • An oroantral perforation is an
unnatural communication
between the oral cavity and maxillary sinus.
• An oroantral fistula is an epithelialized, pathological,
unnatural communication between these two
cavities.

6. • Extraction of teeth
• Destruction of the portion of the floor of the sinus by
periapical lesions
• Perforation of the floor of the sinus and sinus membrane with
injudicious use of instruments
• Forcing a tooth or a root into the sinus during attempted
removal
• Extensive trauma to face
• Chronic infection of maxillary sinus, such as osteomyelitis
• Infected maxillary implant dentures
• Malignancy involving the maxillary sinus such as malignant
granuloma
• Removal of a large cyst or resection of large tumour involving
maxilla

7. IN FRESHOROANTRAL COMMUNICATION:
5 Es:
1. Escape of fluids: from mouth to the nose on the side of
extraction. This happens when the patient rinses or gargles
the mouth following the extraction of a tooth.
2. Epistaxis(unilateral): it is due to blood in the sinus escaping
through osteum into the nostril. It may or may not be
associated with frothing at nostril on the affected side.
3. Escape of air: from mouth into the nose, on sucking, inhaling
or drawing on a cigarette, or puffing the cheeks.

8. 4. Enhanced column of air: causes alteration in vocal
resonance and subsequently change in the voice.
5. Excruciating pain: in and around the region of the affected
sinus, as the local anesthesia begins to wear off.

9. IN LATE STAGE, ESTABLISHED OROANTRAL
FISTULA:
5 Ps:
1. Pain
2. Persistent, purulent or mucopurulent, foul, unilateral nasal
discharge from the affected nostril, especially when head is
lowered down. Unilateral foul or foetid taste and smell.
3. Postnasal drip: the trickling of the nasal discharge from the
posterior nares, down the pharynx. The continuous
swallowing of the foul mucopurulent discharge may lead to
unpleasant taste. This is accompanied by nocturnal cough,
hoarseness, ear ache or catarrhal deafness.

10. 4. Possible sequelae of general systemic toxemic condition:
fever, malaise, morning anorexia, frontal and parietal
headaches and in extreme cases anosmia and cacosmia.
5. Popping out of an antral polyp: the persistent infection in the
antrum may lead to establishment of chronic long standing
oroantral fistula, which may be occluded by an antral polyp.
This can be seen as a bluish red lump extruding through the
fistula.

11. PHYSICAL SIGNS OF ESTABLISHED
OROANTRAL FISTULA:
Early signs:
The early signs are seen when the
blood clot gets disintegrated, so that
the breach in the continuity of antral
lining remains patent;
a) As a result of infection
b) Forceful nose blowing
c) Excessive rinsing of mouth
Late signs and symptoms:
Due to involvement of sinusitis or
established oroantral fistula with or
without rhinitis;
a) Signs and symptoms of sinusitis and
rhinits
b) Escape of air or fluid through nostril
c) Development a lump(polyp)
On examination:
•Discharge of foul smelling pus from the orifice. Sometimes, the pus doesnot
descend freely, maybe due to occlusion of sinus orifice by polyps.

12. SIGNS OF ACUTE SINUSITIS:
Tenderness over the maxilla, especially in the infraorbital
region.
Mild edema of cheek in infraorbital soft tissues.

13. Rarely, patient gets earache, as a referred pain from antrum.
This is attributed to acute otitis media.
Percussion of maxillary premolars and molars related to
affected sinus will lead to pain.
Presence of pus or mucopurulent discharge in middle meatus
and traclking down posterior wall of pharynx.

14. SIGNS AND SYMPTOMS OF CHRONIC
SINUSITIS:
Impairment of sense of smell
Foul smelling of mucopurulent discharge
Herniation of polyp into middle meatus
Prolapse of polyp through the fistula

15. INTRAORAL EXAMINATION:
Descending postnasal floor of mucopurulent discharge
Herniation of polyp into middle meatus
Prolapse of polyp through the fistula

16.  If the fistula is large, it can be assessed from inspection.
 Nose blowing test: compression of anterior nares, followed by gentle
blowing of nose (with mouth open), causes a rise in intranasal
pressure exhibited by the whistling sound as air passes down the open
passage.
 Mouth mirror test
 A wisp of cotton-wool held just below the alveolar opening will
usually be deflected by the air stream.
 Patient is asked to hold fluid within the mouth, fluid can be seen
escaping through the nose. Betadine can be mixed with the fluid to
differentiate between nasal secretion and rinsing fluid.

17.  PURPOSE
1. To protect the sinus from oral microbial flora
2. To prevent escape of fluid and other contents across the
communication
3. To eliminate existing antral pathology
4. To establish drainage through inferior meatus
A fistulous tract present for more than 14 days should be
considered as a chronic fistula.

18.  Management of oroantral communication depends on 2 factors
1. Size of communication:
 Small size communications heals better,
 Large size communication > 5mm may result in chronic oroantral
fistula.
2. Preoperative condition of maxillary sinus:
 If maxillary sinus is infected before surgery even small
communication will not heal.
 If patient has maxillary sinusitis OAC will heal poorly and
chronic oroantral fistula results.

19. • Surgeon should ensure that high quality blood clot is
formed in the socket.
• Advise patient - sinus precautions so that clot will not
dislodge.
• Surgeon must not probe into sinus through socket
because it may introduce foreign bodies and bacteria
into sinus, it may also lacerate sinus membrane.
If size of OAC is
2mm or less in
diameter
• Additional measures are required to maintain blood
clot in the socket.
• Figure of eight suture should be placed over the
socket.
• Some surgeon also place gel foam in the socket to
enhance clotting.
• Advise drugs and sinus precautions
If opening is of
moderate size of 2 to
6mm
• Surgeon should consider repair of OAC with a flap
procedure.
• Most commonly used flap for small opening is buccal
advancement flap.
• Closure should be performed as soon as possible
preferably on the same day.
• Advise drugs and sinus precautions.
• Maintain follow up.
If size of sinus
opening is 7 mm or
large

20. • Do Not drink with a straw.
• Do Not blow your nose.
• Use all medications as directed.
• Do Not play any wind instruments.
• Do Not smoke cigarettes, pipes, or cigars.
• Do Not open your mouth widely.
• Avoid swimming and strenuous exercise for at least one week.
• Eat a soft or liquid diet. Chew on the opposite side of your mouth
as much as possible.
• Continue to brush your teeth but avoid the surgical area. Rinse
three times a day with warm water.
• It is not uncommon to have a slight amount of bleeding from your
nose for several days.

21. A. TREATMENT OF EARLY CASES:
• Cases where oroantral communication is recent and formation
of fistula is not established.
•Ideal treament
a. Immediate surgery repair to achieve primary closure
b. Simultaneous antibiotic prophylaxis to prevent sinus
infection
The immediate primary closure is done by a simple reduction of
the buccal and palatal socket walls, to allow coaptation of
buccal and palatal tissue flaps to close over the defect. A
protective acrylic denture or splint can be used to provide a
barrier to the inadvertent entry of food particles.

22.  Antibiotics:
- These are used until symptoms begin to subside
- It can be started with IV route and later switched over to oral
route.
- Pencillin V 250 to 500mg six hourly is adequate.
 Nasal decongestants:
- These encourage the drainage of pus and secretions.
- e.g. Ephedrine(0.5%) or otrivin nasal drops
3 drops/ 3times daily / 7 days
-

23.  Analgesics:
-NSAIDs: 1.Aspirin 500mg 4 times daily
2. Paracetamol 500mg 3 times daily
3. Ibuprofen 400mg 3 times daily

24. It includes:
a. Whitehead’s varnish pack : the pack is used over the socket
and secured with suture
Whitehead’s varnish:
 Benzoin 10 parts 44g
 Storax 7.5 parts 33g
 Balsam of tolu 5 parts 22g
 Iodoform 10 parts 55g
 Solvent-ether to 1 fl oz or 100 parts
b. Denture plate: it is indicated when surgical repair of fistula
is to be deferred. It provides barrier to prevent entry of food
particles in antrum.

25. • Cases seen more than 24 hours after accident:
- It is preferable to defer the surgical closure until the gingival
edges of the fistula have healed soundly (approx 3 weeks)
- Supportive measures should be given
- Maxillary sinus should be gently irrigated with warm normal
saline, if there is purulent discharge or signs of acute or chronic
sinusitis is seen.
• Cases of long duration(more than a month):
- Surgical closure is required

26.  Depending upon the type of flap used it can be divided into
three groups:
 Buccal flap
 Palatal flap
 Combination of both

30. It is performed to facilitate the drainage at the conclusion of an
operation performed:
i. To close an oro-antralfistula, or
ii. To remove a tooth or a root from sinus.
Drawbacks: It is a controversial surgical procedure for the
following reasons:
(i) It cannot drain the sinus, satisfactorily; as the point created for
drainage is not at the point of dependent drainage; due to the
fact that antral floor is about 1.5 cm below nasal floor,
(ii) It also interferes with ciliary pathways: thus impedes normal
physiological drainage of sinus.

31. Surgical Procedure for Intranasal Antrostomy
i. A small-sized osteotome or gouge is pushed through the inferior
meatus in the nasal cavity, into the maxillary sinus. Then a big
curved artery forceps is passed through this opening and a
iodoform impregnated ribbon gauze pack’s end is grasped into its
beak and pulled out into the nostril. Here a single knot, which is
put in the ribbon gauze will help to keep it secured in the nostril.
The other end of the ribbon gauze is then used to systematically
pack the maxillary sinus cavity in multiple folds, after achieving
proper hemostasis (after Caldwell- Luc operation).

32. ii. An antrostomy can be performed by removing approximately
1 cm of the medial wall of the antrum, which bulges into the
sinus below the level of the inferior turbinate. This antrostomy
should be extended to the level of the floor of the nose. The nasal
mucosa is then incised from the antral surface on three sides and
the nasal mucosal flap thus created is reflected into the antrum.

34. Flap design Palpation of bony edge

35. Excising the fistula and reflect the flap

36. Post-op follow-up

37. Palatal reversal & buccal advancement flap

38.  Functional Endoscopic Sinus Surgery
 Caldwel-Luc procedure
 Lateral Rhinotomy

39. • Purpose
- To restore normal paranasal air sinuses mucociliary function
• Indications
- Recurrent sinusitis with steanosis at the osteomeatal unit
- Chronic hyperplastic sinusitis with obstructive nasal polyp
- Chronic sinusitis with mucocele formation
- Neoplasms
- Orbital celllulitis/abscess unresponsiveness to medical
treatment

40. •Relative Indications
(i) Repair of cerebral spinal fluid leaks
(ii)Selectednasofrontal recess/frontal sinus mucoceles
(iii)Orbital decompression in bilateral exophthalmos
(iv)Sinusmediated cephalagia

41. • This is the classic operation used when medical therapy
fails to treat maxillary sinusitis effectively or when an
open surgical approach is needed to treat a cyst or tumor of
maxillary sinusitis
• Caldwell in 1893 & Henri Luc in 1897

42. 1. Open procedure for removal of root fragments, teeth or foreign
body or an antrolith (stone) from the maxillary sinus.
2. To treat chronic maxillary sinusitis with hyperplastic lining and
polypoid degeneration of the mucosa.
3. Removal of cysts or benign growths from the maxillary sinus.
4. Management of hematoma in the maxillary sinus and to control
post traumatic hemorrhage in the sinus.
5. Zygomaticomaxillary complex fractures involving floor of the
orbit and anterior wall of the maxillary sinus.
6. Removal of impacted canine or impacted third molar.
7. Along with closure of chronic oroantral fistula, associated with
chronic maxillary sinusitis.

43. • Under LA with sedation or under GA
• A semilunar incision is planned in the
buccal vsetibule from canine to 2nd molar,
just above the gingival attacment.
• A mucoperiosteal flap is elevated
• An opening or window is created in the
anterior wall of maxillary sinus.

44. • It is then enlarged in all directions
with Rongeur forceps, to permit the
inspection of sinus cavity.
• Pus should be sucked away and
thorough irrigation of maxillary
sinus is carried out with copious
saline wash.
• Removal of root, tooth gauze, bone
wax or stone is done
• The thickened, infected lining of the
sinus can be elevated with Howarths
periosteal elevator and removed and
sent for histopathology

45. • In case of profuse bleeding- sinus is packed with ribbon gauze
soaked in adrenaline 1:1000 for 1 or 2 minutes
• The antral cavity is irrigated again and can be packed with
iodoform ribbon gauze.
• The incison is closed with 3-0 silk

46. Indication
• well differentiated or low grade tumor such as inverted
papillomas
 tumors of limited extend on the lateral wall of nasal cavity
or medial wall of the antrum

47.  Textbook Of Oral And Maxillofacial Surgery; 4th
Edition; Prof. Dr. Neelima Anil Malik.