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CONTENTS
• INTRODUCTION.
• DEVELOPMENT.
• HISTOLOGY.
• MAXILLARY SINUSITIS .
• ORO-ANTRAL FISTULA.
• CALDWELL -- LUC OPERATION.
• FESS.CONCLUSION.
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INTRODUCTION
• The sinuses are the air spaces
within the pneumatic bones
situated at the frontobasal region
of skull.

• 4 in number. Frontal, Maxillary,
Sphenoidal and Ethemoidal.

• Form the boundaries of nasal
cavity.

• Open into the nasal cavity .

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• Maxillary sinus is a large
pneumatic space present in body
of maxilla.


• Largest of all sinuses.


• Antrum of Highmore –in 1962.
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DEVELOPMENT
• Begin their development as
evagination of the mucosa of the
nasal fossa during the 3
rd
and 4
th

fetal months.



• Grows rapidly from birth to 3
years of age and 6 to 7 years of
age, and then slowly up to 18
years.

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HISTOLOGY
• Maxillary sinus lined by three
layers: epithelial layer, basal
lamina and sub epithelial layer
with periostium.

• Epithelium is pseudo stratified,
columnar and ciliated.

• As cilia beats, the mucous on
epithelial surface moves from
sinus interior towards nasal
cavity.


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ANATOMY
• Four sided pyramid located in
body of the maxilla.

• Anterior wall – facial surface of
maxillary bone

• Posterior wall – infratemporal
surface of maxilla.

• Medial wall – lateral wall of nasal
cavity.

• Roof – floor of orbit.

• Floor – alveolar process of
maxilla.


DIMENSIONS:
Height – 33 mm
Width -23 mm
Length – 34 mm (antero-
posterior)

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• Osteomeatal complex- space
within the middle meatus into
which the maxillary, anterior
ethmoid, and frontal sinuses
drain

• Which is collectively
constituted by the uncinate
process, the maxillary ostium,
the infundibulum, and the
ethmoid bulla.
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• NERVE SUPPLY – anterior, middle, and posterior superior
alveolar nerves, branches of maxillary and infra – orbital
nerves.
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Arterial Supply

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Applied Anatomy:
• In adults, there is a distance of
approximately, 1-1.25cms
between the floor of the sinus
and the root apices of maxillary
posterior teeth.

• Von Bornsdorff (1925) found in
his series that the roots of second
molar were closest to the floor.

• Paatero (1939) also confirmed
this finding ; with the next the
order of frequency were; the first
molar, third molar, second pre
molar, first premolar and canine.
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• Maxillary sinus reaches its normal adult size by the age of 18 -
26 years. Hence the risk of creating oroantral fistula is less in
children and young adults.
• Guven in 1998 indicated that oroantral fistula most frequently
occurs after the third decade of life which agrees with the
results of other authors such as Lin in 1991 and Punwutikorn
and co-workers in 1994.
• Lin et al. in 1991 reported that the maxillary sinus is more
developed in women and that there is therefore greater
possibility of the occurrence of oroantral communication and
fistula in women .
• Periapical involvement, in the form of acute or chronic
abscess in teeth related to floor of sinus, may secondarily
involve maxillary sinus.

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• Whenever antral puncture is carried out, should be made
through the middle meatus in children and through inferior
meatus in adults.

• The antral puncture the inferior meatus is not a point of
dependent drainage for maxillary sinus.

• The floor of the sinus can have three basic positions: beneath
the level of the floor of the nasal cavity, on its level or above
its level.

• The floor of maxillary sinus is about 1.25cms below the floor
of the nose.

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FUNCTIONS:

• Reduces the weight of the skull.
• Adds resonance to the voice.
• Humidifies and warms the inspired air and thus protects the
internal structures, especially the brain against cold and dry
air.
• Moistened the nasal cavity and probably contribute to
olfaction.
• Enhances the facio cranial resistance to mechanical shock.
• Produces bactericidal lysozyme and discharges them to the
nasal cavity.

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MAXILLARY SINUSITIS

• Definition: Inflammation of the mucosa of the maxillary
sinus.



• Pansinusitis: Inflammation of most or all of Para nasal
sinuses simultaneously.


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Classification:
• Acute.
• Sub acute.
• Recurrent acute.
• Chronic.

• A diagnosis of acute sinusitis requires that criteria satisfying a
strong history for sinusitis are present for 1 to 4 weeks.
• Sub acute sinusitis requires that these criteria have existed for
4 to 12 weeks.
• Chronic sinusitis the criteria are present for at least 12 weeks.
• In recurrent acute sinusitis, episodes last < 4 weeks, but the
patient is asymptomatic between episodes.

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ETIOLOGY

• Infection
• Trauma
• Allergy
• Neoplasm.
• Infected cysts.
• Oroantral communication.
• Displaced tooth or root.


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CLINICAL PRESENTATION
MAJOR FACTORS:
• Facial pain/pressure .
• Facial congestion/fullness.
• Nasal drainage/discharge .
• Nasal obstruction/blockage Fatigue
• Hyposmia/anosmia (decreased or absent sense of smell)
• Fever (acute sinusitis only)
• Purulence on nasal endoscopy (diagnostic by itself)
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MINOR FACTOR:
• Headache
• Maxillary dental pain
• Cough
• Halitosis (bad breath)
• Fatigue
• Ear pain, pressure, or fullness
• Fever

*Either two major factors, or one major and two minor, are
required for a diagnosis of rhinosinusitis. Purulence on nasal
endoscopy is diagnostic. Fever is a major factor in only acute
sinusitis.*
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Microbiology:
• Normal flora of maxillary sinus: Streptococci,
Porphyromonas, Prevotella, Fusobacterium.

• Maxillary sinusitis of non odontogenic origin: The important
aerobes are Streptococcus pneumoniae, Haemophilus
influenza, Staphylococcus aureous.Anaerobes are:
Porphyromonas, Prevotella, Peptococcus, Fusobacterium.

• Maxillary sinusitis of odontogenic origin: The predominant
organisms are aerobic Streptococci, and anaerobic
Peptococcus, Peptostreptococcus, Porphyromonas, Prevotella,
Eubacterium sps.





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ROLE OF VIRUSES:
• Influenza virus, rhinovirus, respiratory
syncytial virus, parainfluenza virus, corona
virus may be implicated.

ROLE OF FUNGI:
• Allergic fungal sinusitis- Dematiaceae family,
Aspergillus species.
• Mucoraceae family- diabetics.

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Pathophysiology
PREDISPOSING FACTORS:
• Mechanical obstruction of mucociliary flow,
particularly in the OMC region.
• Defects in ciliary capability to propel the
mucous blanket.
• Abnormal quantity or quality of secretions.
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• Inflammation of mucus membrane of maxillary sinuses.
• Hyperplasia and hypertrophy of mucous membrane.
• Edematous ostium.
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•Drainage of sinus blocked.
•Accumulation of the secretions.
•Bacterial growth.

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DIAGNOSIS:
Radiology:
The abnormalities to be looked for include:
• Evidence of thickening of the mucosa and the boney walls (
caused by chronic sinus diseases).
• Air - fluid level ( caused by accumulation of mucous, pus and
blood).
• Foreign bodies.
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• Acute sinusitis :Affected antrum shows uniform opacity.
Sometimes a fluid level indiscernable.
• Chronic sinusitis: The radiograph shows pansinusitis, fluid
level, thickened lining is also seen

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Trans illumination:


• Carried out by placing a strong light in the centre of the
mouth of the patient with the lips closed.
• The results of the normal sinus will be a definite infra orbital
crescent of light, a brightly lit eye and glowing pupil.
• In case, the antral cavity contains pus, mucous, polyps, blood
and a lining thickened membrane and a fibro-osseous lesions
or a tumor, it will not light up as it was in normal
circumstances.



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ENDOSCOPY
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MEDICAL MANAGEMENT
ANTIBIOTICS:
• Amoxicillin 250-500mgs 8 hrly for 10-14 days.
• Erythromycin 250-500mgs 6 hrly for 10-14 days.
• It has been further recommended that cephalosporins,
macrolides, penicillinase-resistant penicillins, and should be
reserved for failures of first-line therapy or for complications.

DECONGESTANTS:
• Ephedrine sulphate 0.5 -1 %
• Phenylephrine 2%
• Topical decongestants must be used judiciously, however, as
continuance of these medications beyond 3 to 5 days is
associated with reduced duration of action and rebound
vasodilation, a condition known as rhinitis medicamentosa.




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• STEROID THERAPY: Prednisone or methylprednisolone - begin
at 30 mg daily and are tapered over 2 to 3 weeks.

• ANTIFUNGAL AGENTS: Itraconazole 200 mg bid.

• ANTIHISTAMINES: Should be limited to allergic sinusitis.
Antihistamines may cause drying and thickening of nasal
secretions resulting in impaired mucociliary flow.
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SURGICAL MANAGEMENT
INDICATIONS:
• Acute sinusitis with evolving complication.
• Chronic sinusitis that has failed maximum medical
management including at least 3 weeks of broad
spectrum antibiotics.
• Most forms of fungal sinusitis.
• In cases of complicated acute sinusitis and invasive
fungal disease, surgery should be performed on an
emergent basis.
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GOALS OF SURGERY:
• To remove chronically inflamed tissue.
• To restore sinus ventilation.
• To drainage.
• To provide mucociliary clearance.
• Evidence exists that in chronic sinusitis the
inflammatory process involves the underlying
bone. Thus, it is especially important to resect
the bony ethmoid partitions underlying
chronically inflamed mucosa.
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Oroantral communication and fistula
• Definition: An oroantral fistula is an epithelialised,
pathological, unnatural communication between oral cavity
and maxillary sinus.

Etiology:
• Extraction of teeth.
• Periapical lesions.
• Injudicious use of instruments
• Facial trauma.
• Surgical procedures.
• Osteomyelitis.
• Syphilis.
• Infected implant dentures.
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Symptoms of fresh oroantral communication:

• Escape of fluids

• Epistaxis

• Escape of air

• Enhanced column of air.

• Excruciating pain
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Symptoms of established oroantral fistula:

• Pain.
• Persistent purulent or mucoprulent foul unilateral nasal
discharge.
• Post nasal drip.
• Popping out of antral polyp.

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AIMS OF MANAGEMENT:

• To protect the sinus from oral microbial flora.
• To prevent escape of fluids and other contents across the
communication.
• To eliminate existent antral pathology.
• To establish drainage through inferior meatus.

• Hanazawe - oroantral fistula of less than 2 mm diameter has the
possibility of spontaneous healing. Diameter of more than 3 mm
spontaneous healing is hampered because of the possibility of
inflammation of the sinus.
• In 1957 Martensson -- less possibility of spontaneous healing
when the oroantral fistula has been present for 3 to 4 weeks, or
when its diameter is greater than 5 mm.
• The choice of these procedures is influenced not only by the
amount and condition of the tissue available for repair but also by
the size and location of the defect. The palatal rotation flap (PRF),
first described by Ashley in 1939, is a popular method for the
closure of OACs.





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A review of operative techniques
• In 1936 Rehrmann -- buccal flap.

• In 1939 Ashley -- palatinal flap.

• In 1961 Goldman et al. -- applied gold foil to ensure stability of
the flap.

• In 1974 Takahashi and Henderson, and in 1980 James -
mucosal palatinal island flap.



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• In 1974 -- palatinal flap which is carried under the bridge of
the palatinal gingiva along the alveola of the extracted tooth.

• In 1980 Ito et al. isolated the mucosal upper layer and
connective tissue layer of submucosa on a palatinal flap, so
that the submucosal part of the flap covered the fistula, and
the mucosal part of the flap the denuded palatal surface. This
is a so-called palatinal submucosal flap.

• In 1985 Yamazaki et al. described a method of submucosal
palatinal island flap, in which the submucosal layer of the
anterior part of the palatinal flap covers the fistula, and the
mucosal part covers the defect of the palatinal surface in the
frontal part, and with a much thicker flap in the posterior
part.

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• In 1992 Zide and Karas used blocks of hidroxyappatite during
plastics of an oroantral fistula.


• The technique of interseptal-interradicular alveolectomy is
one of the possibilities for treatment of oroantral fistula,
described by Hori et. al in 1995.



• In 1995 Hanazawa et al. closed an oroantral communication
by applying a BFP-buccal fat pad graft


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SURGICAL TECHNIQUES


• Local flaps.

• Distant flaps.

• Grafts.
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Buccal flap advancement operation
• Von Rehermann - 1936.

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ADVANTAGES:
• simple and efficient method .
• Having a broad base --adequate blood supply to the flap.
• Denture may be worn immediately since the palatal mucosa
is intact.
• The donor site closes exactly with no raw area left behind for
granulation.
• The flap mobility is improved by making parallel incisions in
the periosteum at the base of the flap.
• In 1975 Killey and Kay reported success with this method in
93% of cases.
DISADVANTAGES:
• In 1981 Obradovie et al -- significant lowering of the depth of
vestibule.
• cheek oedema .
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MOCZAIR BUCCAL SLIDING FLAP:
• Trapezoidal flap
• WOWERN -- change in the vestibular sulcus is negligible by shifting
the flap one tooth distally.
• Disadvantages -- greater amount of dentogingival detachment .
• May result in variable degree of periodontal diseases.
• Leaves a raw area -- increased scar formation.
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TRANSVERSAL FLAP:
• Schuchardt described this procedure.
• Buccal vestibular height was not affected.
• Does not offer greater mobility.
• Raw area over the donor site following the closure.
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PALATAL FLAPS
Rotational-advancement.

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ADVANTAGES:
• Adequate blood supply.
• Adequate thickness of the flap.
• Preservation of the vestibular height.

DISADVANTAGES:
• Leaves a raw area on the palate .
• Bulge of soft tissue is created at the axis of
rotation.
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ANTERIORLY BASED PALATAL FLAP
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STRIGHT – AVANCEMENT FLAP:


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SUBMUCOUS CONNECTIVE TISSUE FLAP
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PEDICLE ISLAND FLAP
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GRAFT PROCEDURES
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BUCCAL FAT PAD
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TONGUE FLAPS
ANTERIORLY BASED PARTIAL
THICKNESS DORSAL TONGUE
FLAP
POSTERIORLY BASED FULL
THICKNESS LATERAL TONGUE
FLAP
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Caldwell Luc Operation:

History:
• George Caldwell in 1893 from Newyork described a method
of gaining entry into the maxillary sinus via canine fossa.

• Henry Luc in 1897, from Paris also reported the same
procedure as his own later the procedure was accepted as
Caldwell Luc operation.
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Indications:

• For removal of root fragments, teeth, or foreign body, form
maxillary sinus.
• To treat chronic maxillary sinusitis.
• Removal of cysts and growths.
• Management of hematoma.
• Removal of impacted canine and impacted third molar
• Along with closure of chronic oroantral fistula associated with
chornic maxillary sinusitis.
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Functional Endoscopic sinus surgery:
• To restore the mucociliary function.
History
• Hirschmann has been credited as the first surgeon to have
attempeted nasal and sinus endoscopy with a modified
cytoscope in 1901.
• The first discription of endoscopical examining nasal cavity
and the antrum of Highmore were published by Maxwell and
Malt 1925.


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INDICATIONS:

• Recurrent sinusitis.

• Chronic hyperplastic sinusitis.

• Chronic sinusitis with mucocele formation.

• Fungal sinusitis inpatients with diabetes.

• Neoplasms.



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TYPES:

Anand and Panje’s classification-
• Type 1- nasal endoscopy and uncinectomy .
• Type 2- Nasal endoscopy, uncinectomy, bulla ethmoidectomy,
removal of sinus lateralis mucous membrane and exposure of
frontal recess or frontal sinus.
• Type 3- Type 2 plus maxillary sinus antrostomy through the
natural sinus ostium.
• Type 4- Type 3 surgical technique with complete posterior
ethmoidectomy.
• Type 5- Type 4 surgical technique with sphenoidectomy and
stripping of mucous membrane.
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CONCLUSION
Depending upon careful clinical and
radiographic examination, proper assessment
of findings the nature of the disease should be
understood and proper treatment should be
planned. The patient should be called
regularly for follow up.
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References
• Principles of Oral & Maxillofacial Surgery –Peterson
• Treatment of oroantral fistula – Acta Stomatol vol. 36, 2002
• Use of buccal pad of fat for intraoral reconstruction BJOMS:
35; 1997
• Repair of oroantral communications in the 3
rd
molar region by
random palatal flap: IJOMS; 2001
• Grays anatomy – 3
rd
volume
• Closure of oroantral fistula – IJOMS ; 1998: 17
• Oral histology - Tencates

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