Odontogenic Diseases of the Maxillary Sinus Sterling R. Schow EMBRYOLOGY AND ANATOMY MUCOUS-RETENTION PHENOMENON CLINICAL EXAMINATION OF MAXILLARY SINUS OROANTRAL COMMUNICATIONS RADIOGRAPHIC EXAMINATION OF MAXILLARY SINUS Immediate Treatment ODONTOGENIC INFECTIONS OF MAXILLARY SINUS Treatment of Long-Standing Communications TREATMENT OF MAXILLARY SINUSITIS COMPLICATIONS OF SURGERY INVOLVING MAXILLARY SINUS EMBRYOLOGY- AND ANATOMY teeth, to occupy the residual alveolar process. The sinus The maxillary sinuses are air-containing spaces that occu- may then extend virtually to the crest of the edentulous py the maxillary bone bilaterally. They are the first of the ridge. In adults the apices of the teeth may extend into paranasal sinuses (e.g., maxillary, ethmoid, frontal, sphe- the sinus cavity and may be identified readily in the dry noid) to develop embryonically and begin as a mucosal skull lying in the sinus floor. invagination that grows laterally from the middle meatus The sinuses are lined by respiratory epithelium-+ of the nasal cavity at approximately the seventieth day of mucous-secreting, pseudostratified, ciliated, columnar gestation. At birth the sinus cavity is still somewhat less epithelium--and periosteum. The cilia and mucus are nec- than a centimeter in any dimension. essary for the drainage of the sinus, because the sinus After birth the maxillary sinus expands by pneumati- opening, or ostium, is not in a dependent position but lies zation into the developing alveolar process and extends Go thirds the distance up from the inferior part of the anteriorly and inferiorly from the base of the skull, close- medial wall and drains into the nasal cavity. The maxillary ly matching the growth rate of the maxilla and the devel- sinus opens into the posterior, or inferior, end of the semi- opment of the dentition. As the dentition develops, por- lunar hiatus, which lies in the middle meatus of the nasal tions of the alveolar process of the maxilla, vacated by cavity, between the inferior and middle nasal conchae. The the eruption of teeth, become pneumatized. By the time ostium remains at the level of the original lateral extension a child reaches age 12 or 13, the sinus will have expand- from the nasal cavity from which the sinus began forma- ed to the point at which its floor will be on the same hor- tion in the embryo and the location of which is close to izontal level as the floor of the nasal cavity. Expansion of the roof of the sinus (Fig. 19-1). Beating of the cilia moves the sinus normally ceases after the eruption of the per- the mucus produced by the lining epithelium and any for- manent teeth but will, on occasion, pneumatize further, eign material contained within the sinus toward the after the removal of one or more posterior maxillary ostium, from which it drains into the nasal cavity. 418 PART IV Infectior7s CLINICAL EXAMINATION OF MAXILLARY SINUS Clinical examination of the patient with suspected max- illary 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 sur- face of the maxilla between the canine fossa and the zygomatic. buttress. The affected sinus may be markedly tender to gentle tapping or palpation. Further examina- tion may include transillumination of the maxillary sinuses. In unilateral disease, one sinus may be compared with the sinus on the opposite side. The involved sinus shows decreased transmission 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;ests help to distinguish FIG. 19-1 Frontal diagram of midface at ostium or opening of sinus disease, which may cause pain in the upper teeth, maxillary sinuses into middle meatus of nasal cavity. Ostium is in from abscess or other pain of dental origin associated upper. third of sinus cavity. with the molar and bicuspid teeth. 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 Ostium information to either confirm or rule out pathologic con- ditions of the sinus. If additional radiographic informa- tion 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. ~nter~retationof radiographs of the maxillary sinus is not difficult. The findings in the normal antrum are those Sinus to be expected of a rather large, air-filled cavity surround- ed by bone and dental structures. The body of the sinus FIG. 19-2 Lateral diagram of right maxillary sinus with zygoma should appear radiolucent and should be outlined in all removed. Medial sinus wall (i.e., lateral nasal wall) is seen in depth peripheral areas by a well-demarcated layer of cortical of sinus, as is ostium. Maxillary sinus is pyramidal, with its apex bone. It is helpful to compare one side to the other when directed into base of zygoma. 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 The maxillary sinus is the largest of the paranasal (caused by accumulation of mucus, pus, or blood) (Fig. sinuses. It may be described as a four-sided pyramid, with 19-6)) or foreign bodies lying free. Frequently, the apices the base lying vertically on the medial surface and form- of the roots of the posterior maxillary teeth and impacted ing the lateral nasal wall. The apex extends laterally into third molars may be seen to project into the sinus floor the zygomatic process of the maxilla. The upper wall, or (Fig. 19-7). In edentulous areas the sinus may be pneuma- roof, of the sinus is also the floor of the orbit. The poste- tized into the alveolar process and extend almost to the rior wall extends the length of the maxilla and dips into alveolar crest. Complete opacification of the maxillary the maxillary tuberosity. Anteriorly and laterally the sinus may be caused by the mucosal hypertrophy and sinus extends to the region of the first bicuspid or cuspid fluid accumulation of sinusitis, by filling with blood sec- teeth. The floor of the sinus forms the base of the alveo- ondary to trauma, or by neoplasia (Fig. 19-8). lar process. The adult maxillary sinus averages 34 mm in Disruption of the cortical outline may be a result of anteroposterior direction, 33 mm in height, and 23 mm trauma, tumor formation, or surgical procedures that vio- in width. Its volume is approximately 15 cc (Fig. 19-2). late the sinus walls. O~lor!tc:yc~rricI)i\c,lr\c,r oftlfc,\l~~sillrrr-~~ Sirrrr\ CHAPTER 19 419 LVatrrc radioqrap i \liom~~nginuco~sl tliickcn~ncl on T(,~r~ocjrar~o mldfarc takw ~n frontal plane Large, right rnaxlllary slnus floor and lateral wall Patient had oroantral f~s- cystllke radlolucent les~onIS seen to occupy bulk of rlght max~llary tula secondary to removal of flrst molar tooth and symptoms of slnus (arrows) chronic maxillary s~nus~tis COI,-;\L ti axial tornograrn of head in coronal plarie. 1iol1r :?l,i~iI,~~y sinuses are almost totally opacified by rnucosal lesions, as is right nasopliarynx. Such lesions are typical of allergic disease or chronic sinusitis. 420 PART IV Infections FIG. 19-6 A, Waters' radiograph demonstrates bilateral maxillary sinus air-fluid levels (arrows). B, Lat- eral radiograph demonstrates air-fluid levels in maxillary sinus (arrow). FIC. ;':-,Maxrllary molar roots appear to be "rn" sinus, because s~nus has pneumatized around roots. Odontogenic Diseases of the Maxillary Sinus . CHAPTER 19 421 may be seen in chronic sinusitis in periods of acute exac- erbation (Fig. 19-9). Dental pathologic conditions such as cysts or granulo- mas may produce radiolucent lesions that extend into the sinus cavity. They may be distinguished from normal sinus anatomy by their association with the tooth apex, the clinical correlation with the dental examination, and the presence of a cortical osseous margin on the radio- graph, which generally separates the area in question from the sinus itself (Fig. 19-10). Periapical, occlusal, and, occasionally, panoramic radiographs are of value in locating and retrieving foreign bodies within the sinus-particularly teeth, root tips, or osseous fragments-that have been displaced by trauma or during tooth removal (Fig. 19-11). These radiographs should also be used for the careful planning of surgical removal of teeth adjacent to the sinus. ODONTOCENIC INFECTIONS FIG. 19-8 Waters' radiograph shows opacification of left maxillary OF MAXILLARY SINUS sinus by hypertrophied tissue and purulent material (arrows). Patient - - - - -- -- " "--- was previously treated with Le Fort I osteotomy. The mucosa of the sinus is susceptible to infectious, aller- gic, and neoplastic diseases. ~nflammatorydiseases of the sinus, such as infection or allergic reactions, cause hyper- plasia and hypertrophy of the mucosa and produce the signs and symptoms of sinusitis, as well as the radiographic changes seen with these conditions. If the ostium of the sinus becomes obstructed, the mucus produced by the secretory cells lining the walls is collected over long peri- ods. Bacterial overgrowth may then produce an infection. When inflammation develops in any of the paranasal sinuses, whether caused by infection or allergy, the condi- tion is described as sinusitis.