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7/29/2019 Maxillary Sinus Disease -Power Point Presentation
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Good
Morning
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Imaging of salivary gland
Salivary gland
Parotid
Submandibular
Radiographic projections used
OPG Oblique lateral
Rotated PA or AP Intraoral view of the cheek
OPG Oblique lateral Lower 90° occlusal (to show the duct) Lower oblique occlusal (to show the
gland) True lateral skull with the tongue
depressed
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Imaging techniques
Plain films
Contrast radiography- sialography
Ultrasound CT scan
Scintigraphy
Flow rate studies Magnetic resonance imaging (MRI).
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Plain films
Occlusal radiographs- anterior 2/3rd duct
OPG- overlapping
Lateral oblique- 150
view , post 1/3rd
duct Intra buccal
Postero anterior view
Lateral ceph
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Ultrasonography
CT scan
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Sialography is a radiographic procedure that isuseful diagnostic aid in the detection of masses
and pathological processes in the salivary glandsby injection of radio-opaque die through majorsalivary gland ductal system.
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Detection of a calculus / calculi / foreign body
Determination of the extent of destruction of gland secondary
to obstructing calculi / foreign body
Detection of fistulae , diverticuli or strictures
Detection / diagnosis of recurrent swelling and inflammatory
processes
Tumor – location / size
Selection of a site for biopsy
Outline the plane of facial nerve
Residual stone / tumor, fistula or stenosis
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Known sensitivity to Iodine compounds
Acute inflammation of salivary system
Interfere with thyroid function tests
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DEFINITION: Radiopaque substances that have beendeveloped to alter artificially the density of different partsof the patient
IDEAL REQUISITES:
Physiologic properties similar to saliva
Miscibility with saliva
Absence of systemic / local toxicity
Low surface tension and low viscosity
Easy elimination
Absorption and detoxification
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Iodine-based aqueous solutions:
— Ionic monomers :
* iothalmate (e.g. Conray®)
* metrizoate (e.g. Isopaque®)
• diatrizoate (e.g. Urografin®)
— Ionic dimers :
• ioxaglate (e.g. Hexabrix®)
— Non-ionic monomers :
* iopamidol (e.g. Niopam®)
* iohexol (e.g. Omnipaque®)
* iopromide (e.g. Ultravist®)
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-Iodine-based oil solutions such asLipiodol® (iodized poppy seed oil) used for
lymphography and sialography
-Water insoluble organic iodine compounds
eg Pentopaque
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Contrast medium Oil-based
Aqueous
Advantages Densely radiopaque, thus
show good contrast High viscosity, thus slow
excretion from the gland
Low viscosity, thus easilyintroduced
Easily and rapidly
removed from the gland Easily absorbed and
excreted if extravasated
DisadvantagesExtravasated contrast mayremain in the soft tissues formany months, and may
produce a foreign bodyreactionHigh viscosity meansConsiderable pressureneeded to introduce thecontrast, calculi may
be forced down themain duct
Less radiopaque, thus showreduced contrastExcretion from the gland isvery rapid unless used in aclosed system
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EQUIPMENTS
•Polyethylene tubing with blunt end metallic tip
•5 to 10cc syringe
•Lacrimal dilators
•
Contrast medium
•Lemon extract /Lemon slices
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PROCEDURE
3 Phases 1) Preliminary plain film
evaluation
2) Injection / Filling phase
3) Parenchymal / Evacuation
phase
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•Location of orifice of the duct
•
Duct exploration with Lacrimal probe•Insertion of sialographic canula into the duct
•Injection(slow) of contrast medium into the
duct•3 to 4 sets of radiographs are taken during
procedure
-Preliminary plain films-Filling phase films
-Post evacuation phase films
•
Instruction to the patient
PROCEDURE
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3 methods of injecting dye
Simple injection technique Oil-based or aqueous contrast medium is introduced using gentle
hand pressure until the patient experiences tightness or discomfortin the gland, (about 0.7 ml for the parotid gland, 0.5 ml for thesubmandibular gland).
Advantages Simple Inexpensive.
Disadvantages The arbitrary pressure which is applied may cause damage to the
gland Reliance on patient's responses may lead to underfilling or
overfilling of the gland.
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Hydrostatic technique Aqueous contrast media is allowed to flow freely into the gland
under the force of gravity until the patient experiences discomfort.
Advantages The controlled introduction of contrast medium is less likely to cause
damage or give an artefactual picture
Simple Inexpensive.
Disadvantages Reliant on the patient's responses Patients have to lie down during the procedure, so they need to be
positioned in advance for the filling-phase radiographs.
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Continuous infusion pressure-monitored technique
Using aqueous contrast medium, a constant flow rate isadopted and the ductal pressure monitored throughoutthe procedure.
Advantages The controlled introduction of contrast media at known
pressures is not likely to cause damage Does not cause overfilling of the gland Does not rely on the patient's responses.
Disadvantages Complex equipment is required
Time consuming.
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COMPLICATIONS
•Over Distension
•Foreign body Reaction
•
Chronic Inflammatory Process
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Parotid gland
• The duct structure within the gland branchesregularly and tapers gradually towards the peripheryof the gland, the so-called tree in winter appearance
Submandibular gland
• This gland is smaller than the parotid, but the overall appearance is similar — the so-called bush in winter appearance
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Ductal changes associated with: — Calculi — Sialodochitis (ductal inflammation/infection)
• Glandular changes associated with: — Sialadenitis (glandular inflammation/infection) — Sjogren's syndrome
— Intrinsic tumours.
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Calculus:
Filling defects in main duct distal tocalculus, lobules are overfilled.
Ductal dilatation caused by associated
Sialodochitis Emptying film shows retained contrast
media
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Sialodochitis:
Segmental strictures & dilation of larger ducts.“sausage – string ” appearance
Acini & ductules are not dilated
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Glandular changes:
Sialadenitis:- Dots or blobs of contrast mediumwithin the gland, an appearance
known as sialectasis caused by theinflammation of the glandulartissue producing saccular dilatationof the acini- Main duct & inter lobular ductsappear normal in caliber.
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Sjogren`s syndrome:
Wide spread dots / blobs of contrast media within the
gland. “ Snow – storm ” appearance, Punctate Sialectasis.
Due to the wearing of epithelial lining the intercalated
ducts allow escape of contrast media.
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Intrinsic tumors: • An area of underfilling within the gland, due to ductalcompression by the tumour
• Ductal displacement — the ducts adjacent to the tumour areusually stretched around it, known as BALL IN HAND APPEARANCE.• Retention of contrast medium in the displaced ducts during the
emptying phase.
PARA NASAL SINUS
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PARA NASAL SINUS
AND IMAGING
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Normal appearance
Radiolucent cavity in the maxillaWell-defined, dense, corticatedradiopaque marginsInternal bony septa and blood vesselcanals in the walls all produce their
own shadows.Thin lining epithelium is not normallyseen.
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Investigation
Periapical (paralleling or bisectedangle technique)
Dental panoramic
0° occipitomental (0° OM)
Upper oblique occlusal
Area of antrum shown
Floor Base of antral cavity Relationship with upper posterior teeth
Floor Posterior wall Base of antral cavity Relationship with upper posterior teeth Medial wall Allows comparison of both sides
Main antral cavity Lateral wall Roof or upper border
Medial wall Allows comparison of both sides
Floor Lower half of antral cavity Relationship with upper posterior teeth
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True lateral skull
Linear or spiral tomography incoronal or sagittal plane
Computed tomography (CT) orMRI
Main antral cavity Posterior wall Anterior wall
Note: Superimposition of oneantral shadow on the other
Main antral cavity Floor Anterior wall Lateral wall Posterior wall Medial wall Roof or upper border Allows comparison of both sides
(coronal only)
Main antral cavity Floor All walls Roof or upper border Surrounding structures
Allows comparison of both sides Images hard and soft tissue
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Radiological signs for antral disease
Opacity within the antrum — total or partial
- the shape, site and extent of the opacity often
determining the differential diagnosis, e.g. afluid level
Alteration in the integrity of the antral walls,including discontinuity owing to a fracture or
destruction by an intrinsic or extrinsic tumour Alteration in the antral outline, including
expansion or compression owing to an intrinsicor extrinsic lesion
Presence of a foreign body within the antrum.
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Common pathologies affecting antra
• Infection/inflammation — Acute / Chronic sinusitis
• Trauma
— Oro-antral communication
— Fractures — Foreign bodies
• Cysts
— Intrinsic — Extrinsic
• Tumors — Intrinsic — Extrinsic
• Other bone abnormalities
— Fibrous dysplasia
— Paget's disease — Osteo etrosis.
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ACUTE SINUSITIS
Causes • Upper respiratory tract infection, particularly the commoncoldTrauma, including roots or teeth displaced into the antrum orthe formation of an oroantral communication
• Apical infection associated with the upper posterior teeth
CHRONIC SINUSITIS
Causes • Prolonged antral infection • Continued presence of a foreign body or oroantralcommunication.
Radiographic features of acute sinusitis
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Radiographic features of acute sinusitis
Total opacity within the antral cavity
Opaque zone confined to base of antrum, with initialcollection of fluid, before the combination of mucosalthickening and fluid totally opacifies the antrum
Features of apical inflammatory changes, if infectedteeth are involved — resorption and remodellingof the antral floor producing
antral halo
Evidence of a foreign body
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Chronic sinusitis
Mucoperiosteal thickening of the maxillary sinus
Localized at the base of the sinus.
Generalized around the entire wall of the sinus.
Complete filling of the sinus except about theostium on the medial wall.
Complete filling of the sinus.
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Causes of Oroantral communication
Extraction of closely related upperposterior teeth can remove part of theantral floor or fracture the tuberosity
Inappropriate or incorrect use of elevatorsduring root or tooth removal — may alsocause the root, or rarely the tooth, to be
displaced into the antrum.
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Radiographic features
Break in the continuity of the floor may be evident
Characteristic features of acute or chronic sinusitis owingto the ingress of bacteria
Evidence of the displaced root or tooth — a second viewof the antrum with the head in a different position may berequired to ascertain the exact location of the displacedobject
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MUCOCELES AND MUCOUS RETENTION CYSTS
Pathogenesis is obstruction due to inflammation or
allergy.
Main radiographic features
Incidental finding
Well-defined, round, dome-shaped opacity within the antrum Usually no evidence of thickening of the remainder of the
epithelial lining
Usually no alteration of the antral outline
Occasionally bilateral
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Foreign bodies
Causes
Displaced root fragments or teeth
Excess root canal filling material forced through the apexof an upper posterior tooth during endodontics
Antrolith — calcification within the antrum Foreign material pushed into the antrum through an
existing oro-antral communication.
Main radiographic features The presence, position and often the nature of the
foreign body
Occasionally associated sinusitis.
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POLYPS
Thickened mucous membrane of achronically inflamed sinus frequently formsinto irregular folds called polyps.
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Malignant neoplasm affecting antra
Air sinus Investigation
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Air sinus Frontal
Sphenoidal
Ethmoidal
Investigation 0° occipitomental (0° OM) PA skull True lateral skull
Tomography CT/ MRI
0° occipitomental (with the patient's mouthopen)
True lateral skull Submento-vertex (SMV) Tomography CT/ MRI
0° occipitomental
30° occipitomental True lateral skull PA skull Tomography CT /MRI
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Thank You