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oral surgery 4th year > maxillary antrum > Flashcards

maxillary antrum Flashcards

1
Q

3 main fcts of paranasal sinuses

A

resonance to voice
reserve chamber for warming inspired air
reduce weight of skull

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2
Q

embryology

A

form during 3rd and 4th foetal months
- evaginations of mucosa in nasal cavity
maxillary and ethmoid fairly large at birth
sphenoid and frontal - expansion during first few yrs of life

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3
Q

opening - ostium

A

middle meatus (hiatus semilunaris)
opening approx 4mm diameter
located superiorly on medial wall of sinus
- position can predispose to sinusitis - hard to drain
lined with mucosa
can become narrowed/blocked during episodes of inflammation/disease

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4
Q

differential diagnoses

A 
dental
sinus
TMD
tumours
MS
atypical facial pain
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5
Q

clinical significance

A 
OAC/OAF
root in antrum
sinusitis
benign lesions
malignant lesions
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6
Q

when should you suspect a malignant lesion?

A

when you can’t see walls of sinus

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7
Q

which sinus is usually the largest?

A

MS

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8
Q

shape of MS

A

pyramid

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9
Q

dimensions of MS

A

av volumetric space 15ml in adult
37mm high
27mm wide
35mm AP

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10
Q

what are generally found on the posterior wall of the sinus cavity and what is the clinical significance of this?

A

alveolar canals that transport the posterior superior alveolar vessels and nerves to the maxillary posterior teeth
can get referred pain e.g. pts think they have toothache

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11
Q

MS and roots of molars and sometimes premolars

A

may project into the floor
roots may perforate the bone so that only the mucosal lining of the sinus covers them
if PA pathology could inflame the mucosa - can get mucosal thickening

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12
Q

MS lining

A

pseudostratified ciliated columnar epithelium
cilia mobilise trapped particulate matter and foreign material within the sinus and move it towards the ostia for elimination into the nasal cavity

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13
Q

diagnosis of OAC/OAF

A

size of tooth
radiographic position of roots in relation to antrum
bone at trifurcation of roots
bubbling of blood
nose holding test (careful as can create an OAC)
direct vision
good light and suction (echo)
blunt probe (careful as can create an OAC)

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14
Q

OAC pre-op assessment purpose

A

so you can warn pt - explain it is a 2D image so roots may not be as close but there is a risk

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15
Q

management of acute OAC if small or sinus lining intact

A

inform pt
encourage clot
suture margins
small OACs <2mm usually heal with normal blood clot formation and routine mucosal healing

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16
Q

management of acute OAC if large or lining torn

A

close - if you can get primary closure not under tension without a flap then do it
BAF
- 3-sided - straight or slightly splayed for wider base
- need to release periosteum (fibrous, inelastic)
- paint line with scalpel where relieving incisions end
- once you have released it the flap becomes v elastic
so can cover socket w no tension
- non-resorbable (prolene)
- combination of sutures to keep it closed (mattress
sutures evert edges so get better healing as mucosa
not interrrupted

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17
Q

acute OAC antibiotics

A

perforation introduces oral bacteria
use prophylactic antibiotics
7 days
amoxicillin or doxycycline

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18
Q

acute OAC POIs

A 
review appt in a couple of days
don't forcibly blow nose or stifle a sneeze (by pinching nose) - sneeze with mouth open
steam/menthol inhalation to keep sinuses clear
avoid using straw
no smoking
don't prod area
no vigorous mouthwashing
no wind instruments
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19
Q

chronic OAF - pts may complain of

A

problems with fluid consumption (fluids from nose)
problems with speech/singing (nasal quality)
problems playing brass/wind instruments
problems smoking cigarettes/using straw
bad taste/odour/halitosis/pus discharge
- may need to squeeze/run blunt probe over
pain/sinusitis type symptoms

20
Q

management of chronic OAF

A 
may need CBCT
excise sinus tract/fistula
 - if just close over it will reform
 - cut round it up to sinus then pull tube out, excavator for 
    remnants
antral wash out - remove all of the soft GT
BAF
buccal fat pad with BAF
palatal rotational flap
bone graft/collagen membrane
(tongue flap - historical)
21
Q

palatal rotational flap for chronic OAF

A

cut finger like projection of thick mucosa
leave attached and turn over the OAF
leaves raw bit on palate
- can make an acrylic healing plate to protect it while it heals

22
Q

fracture of maxillary tuberosity - aetiology

A 
single standing molar (unsupported bone)
unknown UE molar/8
pathological gemination/concrescence
extraction in wrong order
 - create a last standing molar
inadequate alveolar support
 - have finger and thumb either side at all times
 - if needing too much force stop and do surgical
23
Q

fracture of maxillary tuberosity - diagnosis

A

noise
movement noted both visually or with supporting fingers
>1 tooth movement
tear on palate - sharp bone edges

24
Q

fracture of maxillary tuberosity - management options

A

dissect out and close wound

reduce and stabilise

25
Q

fracture of maxillary tuberosity - dissect out and close wound

A

if small
don’t just pull as you will rip
may need a BAF

26
Q

fracture of maxillary tuberosity - reduce and stabilise

A

if large or have other teeth attached that you don’t want to extract
reduction
- fingers (gauze) or gently w forceps
- may need to disimpact it first
fixation
- needs to be rigid to get bony healing - if flexible splint
will get fibrous healing (CT)
- the more teeth you include the more rigid it will be (as
you can only splint anteriorly)
- ortho buccal arch wire spot-welded with composite (if
can’t get moisture control can use GI but harder to
remove
- (arch bar) - hard to get in and out and bad for PD health
- splints - can get lab to make emergency splint - but
need pt numb to take imp and cover area in vaseline
so don’t rip it out

see pt in a couple of days to check splint

27
Q

fracture of maxillary tuberosity - remember to:

A 
remove or tx pulp
ensure occlusion free
 - reduce tooth to be extracted or soft splint to relieve
ABs
remove tooth 8wks later (SR)
review next day
28
Q

fracture of maxillary tuberosity - POIs

A

antiseptics - cotton bud and CHX round splint
soft diet
painkillers
baby toothbrush from next day

29
Q

root or tooth in MS - management

A

check not in suction/floor/on pt etc
confirm radiographically by OPT, occ, PA (+/- CBCT)
decision on retrieval
- if can see/easy to get
- risk pushing it further
if in doubt or retrieval difficult - refer
rarely may be tucked under intact mucosa, so not in sinus

30
Q

root or tooth in MS - retrival

A

OAF type approach/through socket

  • flap design
  • good light
  • open fenestration with care - may need bone nibblers and electric bur
  • suction - efficient and narrow bore
  • small curettes (discoid)
  • irrigation
  • ribbon gauze - soak it and gently pack into socket then pull it out and sometimes root comes out
  • close as for OAC

Caldwell-luc approach

  • buccal sulcus
  • buccal window cut in bone

ENT

  • endoscopic retrieval
  • go in through ostium and widen it to get root out
31
Q

sinusitis

A

sinus inflammation and infection

32
Q

why does sinusitis often present to the dentist first?

A

symptoms of pain and pressure in maxillary posterior teeth
floor v close to root apices of maxillary posterior teeth
- roots freq extend into sinus cavity

33
Q

sinusitis S+S

A 
facial pain and pressure most freq
congestion/fullness
nasal obstruction
paranasal drainage
hyposmia
fever
headache
dental pain
halitosis
fatigue
cough (constant post-nasal drip)
ear pain
anaesthesia/paraesthesia over cheek
34
Q

aetiology of sinusitis

A

most commonly ppt by the effects of a viral infection
- inflammation and oedema
- obstruction of ostia - sinus can’t empty
- stagnation and trapping of debris within sinus cavity
normal physiological fct further disrupted by the cellular damage that occurs to the mucosal lining
- affects normal ciliary fct
predisposing factors/mucociliary clearance patterns may be altered by:
- allergens
- inflammation
- anatomic abnormalities - opening smaller/in different places
when sinus can no longer evacuate its contents efficiently:
- build up of pressure
- opportune situation for bacterial overgrowth of normal flora

35
Q

sinusitis - important to rule out a dental cause

A

PA abscess
PD infection
deep caries
recent ext socket
TMD
neuralgia or atypical facial pain/chronic midfacial pain
facial pain in absence of obvious dental aetiology requires further investigation

36
Q

indicators of sinusitis and not toothache

A

discomfort on palpation of infraorbital region
a diffuse pain in the maxillary teeth
- can’t identify which tooth
equal sensitivity from percussion of multiple teeth in same region
pain that worsens with head or facial movements

37
Q

aims of tx for sinusitis

A

tx presenting symptoms
reduce tissue oedema - so pt can clear their sinuses
reverse obstruction of the ostia

38
Q

tx for sinusitis

A

decongestants reduce mucosal oedema
local measures first - humidified air - steam/menthol inhalations - go in and out so don’t burn skin
(ABs)

39
Q

decongestants for sinusitis

A

ephedrine nasal drops 0.5%, 1 drop each nostril x3 daily when required
oxymetazoline (nasal spray)

40
Q

ABs for sinusitis

A

only if:

  • symptomatic tx is not effective/symptoms worsen/symptoms severe
  • S+S point to a bacterial sinusitis - purulent discharge lasting 7 or more days, bad taste, pus drainage down back of throat

SDCEP

  • phenoxymethylpenicillin 250mg, 40 tablets, 2 x4 daily
  • doxycycline 100mg, 2 capsules on first day followed by 1 capsule daily for 7 days (if penicillin allergy or intolerance)
41
Q

foreign object in sinus

A 
e.g. tooth, root, fractured endo instrument
if retrievable remove at once
if not
 - inform pt
 - take a radiograph
 - document in pt notes
 - place pt on appropriate meds
 - refer to OMFS or ENT
42
Q

fungal infections

A

v occ a non-resolving sinusitis may be due to a fungal infection
can cause expansion of the bony walls by increased mucus secretion and fungal growth - fungal hyphae grow into walls
hard to tx - sometimes need surgery

43
Q

trauma and iatrogenic factors

A 
can cause sinusitis by violating the integrity of the bony cavity and sinus membrane
sinus wall fracture
orbital floor fracture
RCT
 - initiate PA inflammation at floor of sinus
 - introduce bacteria into sinus
 - file pushed into sinus
tooth ext
 - perforation
 - roots/tooth displaced into sinus
dental implants/sinus lifts
deep PD tx
nasal packing
NG tubes
mechanical ventilation

= a perforation into the sinus will introduce oral bacteria therefore prophylactic ABs should be used

44
Q

benign lesions

A

polyps, papillomas, antral pseudocysts, mucoceles, retention cysts
beware as an inverted papilloma has the potential to become malignant
odontogenic cysts/tumours expanding into sinus
- but grow so may need destruction surgery

45
Q

malignant lesions

A

primary tumours

local spread from adjacent sites

oral surgery 4th year (9 decks)

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