Maxillary sinus disease

Overview

The maxillary sinus is the paranasal sinus that has the most influence on the dentist's job since they are frequently needed to make a diagnosis in connection to orofacial discomfort that may be sinogenic in origin. Maxillary sinus illness is frequently noticed accidentally on radiographs, and dentists must frequently establish a diagnosis and arrange therapy based on image interpretation.

Anatomy and function of the paranasal sinuses

The paranasal sinuses, together with the turbinates, aid in the nasal space's role of warming and humidifying air and contribute to the body's defenses against microbial infiltration. Furthermore, the paranasal sinuses, which are called for the bones inside which they are located, are considered to reduce the weight of the face skeleton and contribute to voice resonance. Although it is improbable that the form and structure of the face and paranasal sinuses evolved as an evolutionary adaptation or artistic feature, they may operate as a crumple zone under severe trauma, shielding the brain.

The sinus lining (ciliated columnar epithelium) generates mucus, which is carried by the movement of cilia in a synchronized pattern across the sinus, frequently against gravity, and, in the case of the frontal sinus, not via the most direct path, to the ostia, where draining into the nasal space occurs. Mucus exits the nasal cavity and enters the nasopharynx before being swallowed.

Symptoms are caused by the stoppage of this essential mechanism, which is frequently caused by diminished ciliary activity or blockage in the presence of illness. Because the ostia of the anterior ethmoid, frontal, and maxillary sinuses are so close together in the middle meatus, inflammation of middle meatal soft tissue sometimes involves more than one sinus.

The maxillary sinus ostium is located high up on the medial wall and is 2.4 mm in diameter on average. Although the bone window is significantly bigger, the effective ostium is decreased by the uncinate process, which is an extension of the inferior turbinate and the surrounding soft tissues. The maxillary sinus can be missing or hypoplastic in rare cases, although it is normally the first to develop, with two major growth spurts at 0–3 years and 7–12 years, correlating with the development and eruption of the permanent teeth and pubertal face growth.

The molar teeth are closest to the maxillary sinus, whereas the premolar teeth are farther away. Ectopic canine teeth are occasionally associated with the maxillary sinus. The sinus grows during life through a process known as pneumonisation, such that the roots of maxillary teeth frequently extend into the air space, and after tooth removal, the sinus floor may be lower than the nasal floor. The diameters of the right and left sinuses are frequently varied.

A wide range of disease processes can affect the maxillary sinus, originating either within the sinus lining, the neighboring paranasal sinuses, the nasal space, dental and oral tissues, or in the surrounding bone with extension into the sinus.

What is Maxillary Sinusitis?

Sinuses are hollow holes beneath the face bones that lead to the nose cavity. The mucous linings of these sinuses are comparable to those of the nasal canal. This wet lining keeps dust and particles out of the nasal cavity. The inflammation of the paranasal sinuses caused by a virus, bacterium, or fungus is known as maxillary sinusitis. An infection can also occur as a result of an allergic reaction, in which the immune system destroys healthy bodily cells. This illness is linked to both bacterial and fungal infections.

The most frequent illness condition involving the paranasal sinuses is inflammatory sinus disease. When the maxillary sinus is implicated, it is the disease entity for which a dentist is frequently requested to give a differential diagnosis.

There are several varieties of sinusitis, including acute and mild sinusitis, each with its own set of symptoms, including face discomfort, high body temperature, toothache, weariness, blocked nose, and more.

Maxillary Sinusitis Causes

The sinuses generate mucus lining, which is responsible for smelling, guarding against dust, clogged noses, and other functions. Among the most likely causes are:

Common cold, or influenza flu.
Viral infections.
Bacterial infections.
Hay fever and other allergies.

Maxillary Sinusitis Symptoms

Sinusitis symptoms differ from cough and cold symptoms. Common symptoms include face discomfort or pressure, nasal congestion or discharge, and a loss of smell. The discomfort is caused by a plugged sinus. Other common symptoms include:

Headache
Bad breath
Fatigue
Cough

Treatment of Maxillary Sinusitis

Acute sinusitis treatment is centered on symptom management and should not include antibiotics unless the patient is pyrexial or there is evidence of infection spreading outside the sinus. 8 Instead, topical nasal decongestants and saline nasal irrigation are used to treat the condition. Topical decongestants, such as ephedrine or xylometazoline, constrict the nasal lining, expanding the paranasal sinus ostia and promoting ciliary outflow.

Most decongestants are now available in spray form and are simple to use. Droplet preparations must be administered with greater care to be successful. Excessive decongestant use might cause nasal discomfort. In general, nasal decongestants should not be taken for longer than 7 days due to rebound mucosal edema after stopping the medication.

Saline irrigation of the nasal cavity is similar to using a warm salty mouthwash in that it removes surface debris and aids sinus discharge. 10 In practice, a 10 ml or 20 ml syringe is used, with the patient forcefully wiping out their nasal cavities while leaning over a sink. There are also proprietary spray and pump delivery devices available.

When the infection has progressed outside the sinuses or the patient is pyrexial with a copious nasal discharge, amoxicillin is the first-line antibiotic of choice. A recent generation cephalosporin antibiotic may be appropriate for patients who have a poor clinical response to amoxicillin. Doxycycline or clarithromycin may be recommended for people who are allergic to penicillins. If a patient is clinically sick or displays evidence of orbital involvement, he or she should be sent to a hospital immediately.

Although general dentists would not prescribe nasal steroids or antihistamines, these medications are occasionally administered for acute sinusitis but play no therapeutic function in lowering patient symptoms.

Chronic Rhinosinus Treatment

Chronic rhinosinus illness does not usually induce face pain, and a dental surgeon is unlikely to diagnose chronic maxillary sinusitis when a patient complains of orofacial discomfort. However, the dental staff should have a basic understanding of chronic rhinosinal disease therapy. The presence or absence of nasal polyps, which can obstruct sinus outflow, is frequently used to determine treatment. Chronic illness, mainly nasal congestion and discharge, is treated in the same way as acute disease, with nasal irrigation and nasal decongestants initially.

Nasal decongestants can be utilized for an extended period of time if they are only administered once daily. When polyps are present, either topical or systemic steroids may be administered. Surgery may be required for chronic or recurring acute illness that does not respond to traditional medical care. Following an evaluation by an ear, nose, and throat surgeon, therapy targeted at restoring normal mucociliary function and sinus clearance may be initiated.

This may include repairing a deviated nasal septum, removing polyps, removing or trimming turbinates, expanding the ostium from the maxillary sinus, and reducing extra tissue in the middle meatus. Because of the lower morbidity compared to more open traditional surgical approaches, this therapy is now routinely performed with the use of fiber-optic instruments.

Maxillary Sinusitis Prevention

To prevent the occurrence of this disease, one should take care of the following things:

Taking antibiotic medication.
Taking immunotherapy such as allergy shots.
Avoid breathing dry air.
Reduce smoking.

Fungal disease of the maxillary sinus

The fungus Aspergillus, which lives among moulds and spores and is routinely breathed into the respiratory system, is responsible for the majority of fungal diseases of the maxillary sinus. When Aspergillus infection arises in response to oral foreign objects, the infection is generally confined inside the maxillary sinus.

Infection foci can cause dystrophic calcification and rhinolith development, which can be observed on dental radiographs. Large rhinoliths are referred to as fungal balls. Treatment is often surgical, with the removal of any underlying factor, and is increasingly being administered endoscopically with the goal of restoring normal mucociliary function.

However, in immunocompromised patients, such as those with poorly controlled diabetes, HIV infection, or chemotherapy, fungal infections such as aspergillosis or mucormycosis may spread beyond the sinus into the orbit, temporal fossa, or oral cavity, causing symptoms and signs suggestive of malignant disease.

Disease can sometimes spread to the brain. While the majority of these patients will be clinically sick and in a hospital environment, the alert dental practitioner can help spot early indications or symptoms.

Silent sinus syndrome

Silent sinus syndrome, also known as imploding antrum syndrome, is a rare illness condition characterized by unilateral collapse of the maxillary sinus and orbital floor in the absence of sinus symptoms and prolonged hypoventilation. It is characterized by a downward bending of the orbital floor and a decrease in the size of the maxillary sinus and commonly appears with enophthalmos and hypoglobus. The diagnosis is made by clinical suspicion, followed by CT or MRI.

Endoscopic sinus surgery is used to re-establish maxillary sinus airflow, as well as trimming of a lateralized middle turbinate if discovered, cautious uncinectomy, and middle meatal antrostomy. Typically, bone remodelling occurs spontaneously over the next several months to return the orbit to its previous position.

If this fails, orbital floor repair is explored; however, there is significant debate in the literature about the timing of this portion of the operation, with some centers proposing repair at the same time as the initial surgery.

The frontal sinus is the most usually affected by pneumosinus dilatans, in which one or more sinuses are dilated without functional change, followed by the sphenoid, maxillary, and ethmoidal sinuses. Although the origin is unknown, hypotheses include mild trauma and sinus overaeration. Surgical decompression and maxilloplasty are used to treat the condition.

Benign tumors of the maxillary sinus

A variety of benign tumors, including papillomas, fibro-osseous lesions, salivary gland tumors, mesenchymal tumors, and vasiform tumors, can affect the maxillary sinus. The most essential and often encountered are mentioned below.

Papillomas

Sinonasal papillomas are characterized as inverted, cyclindrical, or everted, with inverted papillomas being the most frequent. Inverted papilloma accounts for around 0.5–4% of all nasal malignancies and is 25 times less common than conventional nasal polyps.

Inverted papillomas are benign epithelial tumors that often form from the lateral nasal wall or the maxillary or ethmoid sinuses, with the epithelium inverted into the underlying stroma but an intact basement membrane. They can, however, occur in isolation, affecting the maxillary sinus. Despite being a benign tumor, its propensity for local aggression, high recurrence rate, and malignant association necessitate aggressive treatment.

Inverted papillomas are benign epithelial tumors that often develop from the lateral nasal wall or the maxillary or ethmoid sinuses, with the epithelium inverted into the underlying stroma but an intact basement membrane. They can, however, arise alone and harm the maxillary sinus. Despite its benign nature, the tumor's proclivity for local aggressiveness, high recurrence rate, and malignant association need vigorous treatment.

The most common treatment is surgical excision, which may be done endoscopically in the great majority of cases. To guarantee a successful excision and reduce the risk of recurrence, all diseased mucosa should be removed before continuing to a subperiosteal dissection, which should involve the removal of all sclerotic bone, with or without a medial maxillectomy.

Tumors with attachments to the anterior wall of the maxillary sinus were previously considered to be unreachable endoscopically, however innovative procedures such as a maxillary medial sinusotomy have been reported, allowing the bounds of what is feasible endoscopically to be further stretched. Patients should be monitored for at least three years.

Salivary gland tumors

Pleomorphic adenomas in the nasal cavity are uncommon, especially in the maxillary sinus. They are benign tumors that can be treated with surgical excision, either endoscopically or with a combination technique. Both recurrence and malignant transformation have been recorded, necessitating caution. Oncocytomas, which are relatively rare in the maxillary sinus, are tumors consisting of epithelial or myoepithelial cells with significant granular eosinophilic cytoplasm. Because malignant change has been documented, excision is advised.

Mesenchymal tumors

Fibromas, lipomas, and myxomas are all uncommon benign maxillary sinus tumors. Endoscopic surgical excision is used in all cases, however because myxomas are locally aggressive and have a high recurrence rate, a large local excision is indicated.

Vasiform tumours

Haemangiopericytomas are uncommon head and neck tumors that contain pericytes (extracapillary cells) scattered throughout normal vascular channels. They can be difficult to identify histologically from sarcomatous lesions and have a varying malignant potential. Wide local excision is required due to late recurrences, with systemic metastases detected in up to 10% of cases. Long-term follow-up is required.

Hemangiomas are vascular lesions that can affect the whole sino-nasal cavity but are infrequently discovered in isolation in the maxillary sinus. They may be removed endoscopically, although preoperative embolization may minimize intraoperative hemorrhage and speed up the procedure.

Malignant disease of the maxillary sinus

Malignancy in the paranasal sinuses is extremely uncommon, accounting for 1.0 % of all malignancies, with around 80% of these cancers occurring in the maxillary sinus and a smaller incidence in the ethmoid sinus. Malignant sphenoid and frontal sinus illness is extremely uncommon. Squamous cell carcinomas account for over 80% of all cancers, with acinic cell carcinomas accounting for 10%. Metastatic sickness begins in the bone and spreads into the sinus cavity.

Squamous cell carcinoma (SCC) is the most prevalent tumor of the paranasal sinuses; nonetheless, SCC of the maxillary sinus alone is uncommon, accounting for fewer than 3% of all head and neck carcinomas. Patients frequently appear late, when the tumor volume has caused oral, orbital, or nasal discomfort.

Unfortunately, malignant illness of the paranasal sinuses sometimes manifests at a late stage, when the tumor has grown large enough to produce symptoms. The mucosa of the paranasal sinuses is not as easily accessible for routine inspection as the oral mucosa, and early mucosal abnormalities are not recognized or explored.

A dental practitioner can help in the diagnosis of a patient with maxillary sinus cancer. A combination of patient complaints and clinical indicators should raise the possibility of maxillary sinus cancer, necessitating prompt referral to an appropriate specialist. Unfortunately, people have been known to be treated for lengthy periods of time under the idea that their symptoms are caused by chronic inflammatory rhinosinal disease, only to be diagnosed with cancer at a later date.

Multidisciplinary teams with involvement from the surgical disciplines of oral and maxillofacial, ear, nose, and throat, and plastic and reconstructive surgery handle maxillary sinus cancer. This study does not intend to explain treatment for sinonasal malignancy, and interested readers are directed to more extensive sources.

Evaluation of the Maxillary Sinuses

A patient suffering from solitary maxillary sinus Disease may exhibit a variety of clinical symptoms or indications. Pain, unilateral nasal blockage, and epistaxis are the most typical presenting symptoms, although patients may also complain of orbital problems, altered face symmetry, or, in rare cases, oral cavity symptoms. A complete clinical examination, including a rigorous nasendoscopic examination of the nasal cavity, is required and may reveal polyps, pus, or a mass in the nose, indicating the source of the symptoms.

CT scanning is largely acknowledged as the examination of choice for examining the paranasal sinuses, and in-office cone-beam CT scanning is gaining favor among endodontists to determine if isolated maxillary illness is odontogenic in nature.

In the instance of a cancer, MRI can more easily demonstrate cerebral extension or perineural invasion, or separate fluid from soft tissue. It's especially beneficial for detecting fungal illness with hyperintensity on T1-weighted pictures and hypointensity on T2-weighted images.

The utility of MRI in the diagnosis of silent sinus syndrome has also been demonstrated. In the evaluation of ICU patients with suspected maxillary sinusitis, ultrasound assessment of the maxillary sinuses has been used as a bedside test to detect the presence of fluid in the sinus in those patients too ill to be transported for a CT scan – a useful adjunct to conventional cross-sectional imaging.

Conclusion

The maxillary sinus is the paranasal sinus that has the most influence on the dentist's job since they are frequently needed to make a diagnosis in connection to orofacial discomfort that may be sinogenic in origin. Maxillary sinus illness is widespread, and it can be caused by a variety of conditions.

Patients usually arrive late because lesions are frequently permitted to develop to a substantial extent before becoming symptomatic, making therapeutic choices more limited and challenging. Proper clinical and imaging examination allows for precise diagnosis, and lesions are frequently effectively handled endoscopically.