2 Sinusitis Dental

7/28/2019 2 Sinusitis Dental

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Sinusitis

Anatomy• Paranasal Sinuses

Anatomy

• Lateral View of Sinuses

Paranasal Sinus Anatomy

Sinusitis

• Definition: – Inflammation of the linings mucosa of the

paranasal sinuses. – Either individually or collectively (pansinusitis

Sinusitis• Inflammation of paranasal sinuses

Sinusitis

• Etiology:

I- Nasal Causes (Rhinogenic 80%) – Acute rhinitis : spread of infection either:

• Directly, enhanced by nose blowing, sneezing orswimming.

• Submucosal lymphatics –

Iatrogenic sinusitis by using nasal packs to stopbleeding

– Swimming or diving in infected swimming pool

Sinusitis

• Etiology:II- Dental Causes (10%):

– Dental abscess of the upper 2 nd premolar or 1 st molar

teeth → maxillary sinusitis. – Faulty tooth extraction → oroantral fisula & Maxillary

sinusitis.

III- Traumatic Causes (10%): – Direct trauma to the sinuses. – F.B in the nose or tooth roots. – Barotrauma

Sinusitis

• Predisposing factors:

I- General factors: – Low resistance & malnutrition – Bad hygiene – Overcrowding & Poor general environment – Endocrine abnormalities – Respiratory disease as cystic fibrosis &

bronchiectasis

Sinusitis

• Predisposing factors:II- Local factors:

– Obstructive lesions: interfere with normalventilation & flow of mucous as: nasal allergy,polypi, adenoids, Hypertrophied turbinates &deviated nasal septum

– Factors inhibiting ciliary action :• Tobacco smoking or alcohol• Nasal trauma (physical or chemical)• Topical nasal medications

Sinusitis

• Bacteriology:Virus infection:

– Most cases of acute sinusitis are viral in origin then

become secondary infected by bacteriaBacterial infection:In rhinogenic infection:

• staph.aureus(45%), strept hemolyticus, pneumococci &hemophilus influenza

In dental infection:• Anaerobic bacteria as anaerobic streptococci, stapylococci &

B. coli

Acute Sinusitis•

SymptomsGENERAL :• Fever, headache, malaise & anorexiaLOCAL :

– Nasal obstruction – Nasal discharge & Postnasal discharge (The discharge is

unilateral and of foetid odour in cases of dental origin) – Unpleasant taste – Smell affection: anosmia (loss of smell)

or cacosmia ( perception of bad smell) – Epiataxis – Pain over the sinus involved or referred along branches of

nerve involved

Acute Sinusitis

• Maxillary pain: – Throbbing pain – Over the cheek –

Referred to the teeth, ear & frontal region – Increases on coughing & bending

• Frontal pain: – Severe pain – Over the forehead – Periodic i.e starts 1-2 hours after rising in the morning

& decreases in the afternoon

Acute Sinusitis

• Ethmoidal pain: – Feeling of pressure – Over the nasal bridge – Referred to parietal eminence – Aggravated by eye movement

• Sphenoidal pain: –

Variable & persistent – Deep seated in the head – Referred to the periphery of the head

Acute Sinusitis

• SignsI- External signs:

– swellowing & oedema:• Maxillary: over the cheek & spread to the lower eyelid• Frontal: over the frontal sinus & spread the lower

eyelid – Tenderness upon pressure:

• Maxillary: over the cheek• Frontal : over the sinus floor• Ethmoid: over the lacrimal bone

Acute Sinusitis

• SignsII- Anterior rhinoscopy & nasal endoscopy:

– Congested swollen nasal mucosa –

Pus or mucopus in:• Anterior on the middle meatus (Frontal)• Posterior in the middle meatus (Maxillary)• Superior mearus ( Post. Ethmoid & Sphenoid)

III- Examination of the pharynx: – Postnasal disacharge tickling over the palate &

post.pharyngeal wall

Acute Sinusitis

• Investigations:Transilluminatin: shows opacification of the involvedsinus

X-Ray Examination (occipitomental view with openmouth):

– Fluid level – Opaque sinus – Thickened mucosa

Culture & sensitivity test for the causative organisms

Photo Image of Sinus Transilluminator

Transillumination of Frontal Sinus

Transillumination of Maxillary Sinus

Normal Water’s and Towne’ s Views of theSinuses

Lateral View Showing NormalSphenoid Sinus

X-Ray Image of Sinuses with MaxillarySinusitis

CT Scan Maxillary and Ethmoid Sinuses

Acute Sinusitis

• Treatment: Aim of treatment:

– Relief of pain – Restoration of ciliary activity – Restoration of patency of the sinus ostia – Control of bacterial infection

Acute Sinusitis

• Treatment:Treatment is mainly medical and includes:

– Antibiotics –

Nasal decongestants (local & general) – Antipyretics & analgesics – Antiallergics for nasal allergy

Dental infections will require treatment of the causeand irrigation of the sinus after subsidence of theacute stage

Oro-antral fistula

Definition:

An abnormal communication between themaxillary antrum and the oral cavity

Oro-antral fistula

Types:• Alveolar: This is the commonest type and usually

follows traumatic dental extraction.• Sublabial: This may arise as a complication of a

CaldWell-Luc operation.• Palatal: This may from palatal malignancies or

granulomata or follow palatal fenestration or partialmaxillectomy operation.

Oro-antral fistula

Investigations:• X-Ray paranasal sinuses ( occipitomental view & a

radiopaque probe in the fistula before imaging): Thisreveals maxillary sinusitis and the fistula tract.

• CT scan Paranasal sinuses : This shows the exactpathology inside the maxillary sinus and its drainage.

• Nasal & Sinus endoscopy

Oro-antral FistulaInvestigations:1. CT scan PNS2. C&S for discharge if

infectedTreatment:• Presenting early:

1. Conservative2. 1ry sutures

• Presenting late:1. Radical antrostomy2. Closure by palatal or

buccal flap

Oro-antral fistulaTreatment:

B- Old fistula:• Treat maxillary sinusitis by:• Medical measures• Repeated antral lavage• Caldwell-luc operation

A- Recent fistula (at time of extraction):

• Remove any remaining roots• Primary closure of the fistula by

suture

Closure of the fistula:• Small fistula:• Remove any remaining roots• Fresh the edges of the

fistula• Suture the edges

Large fistula:Buccal flapIt is thin, obliterates the

buccogingival sulcus & mayinterfere with denturesPalatal flapBetter than buccal flapbecause it is thicker & has a

rich blood supply from thepalatal arteries

Chronic sinusitis

• Etiology:Recurrent acute attacks of sinusitis due to: – Malmanagement of the acute state – Persistence of the predisposing causes e.g.

adenoid, DS, Nasal polyps , allergy & dental

infection

Clinical picture

• Resembles that of the acute form but is muchmilder unless there is an acute exacerbation.

The characteristic symptoms include : – Nasal obstruction (intermittent) – Nasal discharge (purulent or mucopurulent) – Postnasal discharge (leading to chronic pharyngitis,

tonsillitis, laryngitis, chronic cough, gastritis &digestive disturbance)

– Headache

Treatment1. Medical Treatment ( as in acute sinusitis)2. Surgical Treatment• Chronic maxillary sinusitis:

– Maxillary sinus punctures with instillation of antibiotics or

cortisone solution – Intranasal antrostomy to improve the drainage by constructinga large naso-antral window in the inferior meatus.

– Radical antrostomy or Caldwell-Luc operation is indicated toremove all the diseased mucosa of the sinus in cases of

intractable infection. The maxillary sinus is approached througha sublabial incision, opening the anterior wall of the sinus andremoving all the pathological mucosa.

– Endoscopic sinus surgery has now largely replaced all the otheroperations. Its aim is to remove all pathological mucosa andcorrect anatomical abnormalities obstructing the sinus drainage

2 Sinusitis Dental

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