Maxillary sinus

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Maxillary sinus
Gray1199 en.svg
Outline of bones of face, showing position of air sinuses. Maxillary sinus is shown in blue.
Maxillary sinus - medial view.png
Left maxilla, medial view. Maxillary sinus entry shown in red.
Details
Artery Infraorbital artery, posterior superior alveolar artery
Nerve Posterior superior alveolar nerve, middle superior alveolar nerve, anterior superior alveolar nerve, and infraorbital nerve
Identifiers
Latin sinus maxilliaris
MeSH D008443
TA98 A02.1.12.023
TA2 780
FMA 57715
Anatomical terminology

The pyramid-shaped maxillary sinus (or antrum of Highmore) is the largest of the paranasal sinuses, located in the maxilla. It drains into the middle meatus of the nose [1] [2] through the semilunar hiatus. It is located to the side of the nasal cavity, and below the orbit. [2]

Contents

Structure

It is the largest air sinus in the body. [1] [3] It has a mean volume of about 10 ml. [1] [ verification needed ] It is situated within the body of the maxilla, [1] [3] [4] but may extend into its zygomatic and alveolar processes when large. It is pyramid-shaped, with the apex at the maxillary zygomatic process, and the base represented by the lateral nasal wall. [4]

It has three recesses: an alveolar recess pointed inferiorly, bounded by the alveolar process of the maxilla; a zygomatic recess pointed laterally, bounded by the zygomatic bone; and an infraorbital recess pointed superiorly, bounded by the inferior orbital surface of the maxilla. The medial wall is composed primarily of cartilage. [1] [3]

Walls

The nasal wall of the maxillary sinus, or base, presents, in the disarticulated bone, a large, irregular aperture that communicates with the nasal cavity.[ citation needed ] In the articulated skull this aperture is much reduced in size by the following bones:

The sinus communicates through an opening into the semilunar hiatus on the lateral nasal wall.[ citation needed ]

The medial wall is composed primarily of cartilage. [1] [3]

On the posterior wall are the alveolar canals, transmitting the posterior superior alveolar vessels and nerves to the molar teeth.[ citation needed ]

The floor is formed by the alveolar process, and, if the sinus is of an average size, is on a level with the floor of the nose; if the sinus is large it reaches below this level.[ citation needed ] Projecting into the floor of the antrum are several conical processes, corresponding to the roots of the first and second maxillary molar teeth; in some cases the floor can be perforated by the apices of the teeth.[ citation needed ]

The roof is formed by the floor of the orbit. It is traversed by infraorbital nerves and vessels.[ citation needed ]

Features

The infraorbital canal forms a ridge at the junction of the roof and anterior wall of the sinus; [4] additional ridges are sometimes seen in the posterior wall of the cavity and are caused by the alveolar canals.[ citation needed ]

Innervation

The mucous membranes receive their mucomotor postganglionic parasympathetic nerve fibres from the pterygopalatine ganglion.[ citation needed ]

The superior alveolar (anterior, middle, and posterior) nerves, branches of the maxillary nerve provide sensory innervation.[ citation needed ]

Microanatomy

The sinus is lined with mucoperiosteum, with cilia that beat toward the ostia. This membranous lining is also referred to as the Schneiderian membrane, which is histologically a bilaminar membrane with pseudostratified ciliated columnar epithelial cells on the internal (or cavernous) side and periosteum on the osseous side. The size of the sinuses varies in different skulls, and even on the two sides of the same skull. [3]

Relations

The roof of the sinus is also the floor of the orbit. Posterior to the sinus and its wall are the pterygopalatine fossa and the infratemporal fossa. [4]

Variation

After puberty, the maxillary sinus rapidly increases in size. Its size is variable in the adult; if large, it may extend into the zygomatic process and alveolar process of the maxilla. [4]

Extension into the maxillary alveolar process may cause the roots of the molars and even premolars to lie just beneath the floor of the sinus or even project through the floor and into the sinus; in such cases, the roots of the teeth are typically surrounded by a thin layer of bone, but may sometimes lie directly underneath the mucous membrane of the sinus. Projection of the roots into the maxillary sinus is more common in advanced age due to bone resorption. In such cases, tooth extraction can create a fistula between the oral cavity and the sinus that nevertheless usually resolves spontaneously. [4]

Development

Maxillary sinus is the first paranasal sinuses to form. At birth, it is about 6 to 8 cm3 in volume, elongated, as is orientated in antero-posterior direction, located at the next to the medial orbital wall of the eye. The lateral wall of the maxillary sinus goes beneath the medial orbital wall during the first year of life, extends laterally pass the infraorbital groove by the age of four years, and reach the maxilla by the age of nine years. [5] After the first permanent tooth erupted at the age of six to seven, aeration of maxillary sinus is the main growth feature. [5] [6] At the final phase of aeration, the floor of maxillary sinus is four to five milimetres below the floor of nasal cavity. However, timing of maxillary sinus growth is variable in different people. [5]

The maxillary sinus can normally be seen above the level of the premolar and molar teeth in the upper jaw. This dental x-ray film shows how, in the absence of the second premolar and first molar, the sinus became pneumatized and expanded towards the crest of the alveolar process (location at which the bone meets the gum tissue). Pneumatized max sinus.jpg
The maxillary sinus can normally be seen above the level of the premolar and molar teeth in the upper jaw. This dental x-ray film shows how, in the absence of the second premolar and first molar, the sinus became pneumatized and expanded towards the crest of the alveolar process (location at which the bone meets the gum tissue).

Clinical significance

Maxillary sinusitis

CT Brain showing air-fluid level in bilateral maxillary air sinuses post brain trauma. Maxillary sinusitis will also shows similar air-fluid collection and should be rule out from history taking. CT Brain showing air-fluid levels of bilateral maxillary air sinuses post brain trauma.jpg
CT Brain showing air-fluid level in bilateral maxillary air sinuses post brain trauma. Maxillary sinusitis will also shows similar air-fluid collection and should be rule out from history taking.

Maxillary sinusitis is inflammation of the maxillary sinuses. The symptoms of sinusitis are headache, usually near the involved sinus, and foul-smelling nasal or pharyngeal discharge, possibly with some systemic signs of infection such as fever and weakness. The skin over the involved sinus can be tender, hot, and even reddened due to the inflammatory process in the area. On radiographs, there is opacification (or cloudiness) of the usually translucent sinus due to retained mucus. [7]

Maxillary sinusitis is common due to the close anatomic relation of the frontal sinus, anterior ethmoidal sinus and the maxillary teeth, allowing for easy spread of infection. Differential diagnosis of dental problems needs to be done due to the close proximity to the teeth since the pain from sinusitis can seem to be dentally related. [1] Furthermore, the drainage orifice lies near the roof of the sinus, and so the maxillary sinus does not drain well, and infection develops more easily. The maxillary sinus may drain into the mouth via an abnormal opening, an oroantral fistula, a particular risk after tooth extraction.

Oro-antral communication (OAC)

An OAC is an abnormal physical communication between the maxillary sinus and the mouth. This opening is only present when the structures that normally separates the mouth and sinus into 2 separate compartments are lost. [8]

There are many causes of an OAC. The most common reason is following extraction of a posterior maxillary (upper) premolar or molar tooth. Other causes include trauma, pathology (e.g. tumours or cysts), infection or iatrogenic damage during surgery. Iatrogenic damage during dental treatment accounts for nearly half of the incidence of dental-related maxillary sinusitis. [9] There is always a thin layer of mucous membrane (Schneiderian membrane) and usually bone between the roots of the upper back teeth and the floor of the maxillary sinus. However, the bone can vary in thickness in different individuals, ranging from complete absence to 12mm thick. [9] Therefore, in certain individuals the membrane +/- the bony floor of the sinus can be perforated easily, creating an opening into the mouth when a tooth is extracted. [10]

An OAC that is smaller than 2mm can heal spontaneously i.e. closure of the opening. [11] Those that are larger than 2mm have a higher chance of developing into oro-antral fistula (OAF). [11] The passage is only defined as an OAF if it is persistent and lined by epithelium. [11] Epithelialisation happens when an OAC persist for at least 2–3 days and oral epithelial cells proliferate to line the defect. Large defects (more than 2mm) should be surgically closed as soon as possible to avoid accumulation of food and saliva which could contaminate the maxillary sinus, leading to infection (sinusitis). [11] Various surgical techniques can be employed to manage an OAF but the most common involves pulling and stitching some soft tissue from the gum to cover the opening (i.e. soft tissue flap). [11]

Sinusitis treatment

Traditionally the treatment of acute maxillary sinusitis is usually prescription of a broad-spectrum cephalosporin antibiotic resistant to beta-lactamase, administered for 10 days. Recent studies have found that the cause of chronic sinus infections lies in the nasal mucus, not in the nasal and sinus tissue targeted by standard treatment. This suggests a beneficial effect in treatments that target primarily the underlying and presumably damage-inflicting nasal and sinus membrane inflammation, instead of the secondary bacterial infection that has been the primary target of past treatments for the disease. Also, surgical procedures with chronic sinus infections are now changing with the direct removal of the mucus, which is loaded with toxins from the inflammatory cells[ citation needed ], rather than the inflamed tissue during surgery. Leaving the mucus behind might predispose early recurrence of the chronic sinus infection. If any surgery is performed, it is to enlarge the ostia in the lateral walls of the nasal cavity, creating adequate drainage. [7]

Cancer

Carcinoma of the maxillary sinus may invade the palate and cause dental pain. It may also block the nasolacrimal duct. Spread of the tumor into the orbit causes proptosis. [1]

Age

With age, the enlarging maxillary sinus may even begin to surround the roots of the maxillary posterior teeth and extend its margins into the body of the zygomatic bone. If the maxillary posterior teeth are lost, the maxillary sinus may expand even more, thinning the bony floor of the alveolar process so that only a thin shell of bone is present. [7]

History

The maxillary sinus was first discovered and illustrated by Leonardo da Vinci, but the earliest attribution of significance was given to Nathaniel Highmore, the British surgeon and anatomist who described it in detail in his 1651 treatise. [12]

See also

Related Research Articles

<span class="mw-page-title-main">Paranasal sinuses</span> Air-filled spaces surrounding the nasal cavity

Paranasal sinuses are a group of four paired air-filled spaces that surround the nasal cavity. The maxillary sinuses are located under the eyes; the frontal sinuses are above the eyes; the ethmoidal sinuses are between the eyes and the sphenoidal sinuses are behind the eyes. The sinuses are named for the facial bones and sphenoid bone in which they are located. Their role is disputed.

Articles related to anatomy include:

<span class="mw-page-title-main">Maxilla</span> Upper jaw bone

In vertebrates, the maxilla is the upper fixed bone of the jaw formed from the fusion of two maxillary bones. In humans, the upper jaw includes the hard palate in the front of the mouth. The two maxillary bones are fused at the intermaxillary suture, forming the anterior nasal spine. This is similar to the mandible, which is also a fusion of two mandibular bones at the mandibular symphysis. The mandible is the movable part of the jaw.

<span class="mw-page-title-main">Orbit (anatomy)</span> Cavity or socket of the skull in which the eye and its appendages are situated

In anatomy, the orbit is the cavity or socket/hole of the skull in which the eye and its appendages are situated. "Orbit" can refer to the bony socket, or it can also be used to imply the contents. In the adult human, the volume of the orbit is 30 millilitres, of which the eye occupies 6.5 ml. The orbital contents comprise the eye, the orbital and retrobulbar fascia, extraocular muscles, cranial nerves II, III, IV, V, and VI, blood vessels, fat, the lacrimal gland with its sac and duct, the eyelids, medial and lateral palpebral ligaments, cheek ligaments, the suspensory ligament, septum, ciliary ganglion and short ciliary nerves.

<span class="mw-page-title-main">Ethmoid sinus</span> Air-filled space near the nasal cavity

The ethmoid sinuses or ethmoid air cells of the ethmoid bone are one of the four paired paranasal sinuses. Unlike the other three pairs of paranasal sinuses which consist of one or two large cavities, the ethmoidal sinuses entail a number of small air-filled cavities. The cells are located within the lateral mass (labyrinth) of each ethmoid bone and are variable in both size and number. The cells are grouped into anterior, middle, and posterior groups; the groups differ in their drainage modalities, though all ultimately drain into either the superior or the middle nasal meatus of the lateral wall of the nasal cavity.

<span class="mw-page-title-main">Maxillary nerve</span> Branch of the trigeminal nerve responsible for the mid-face

In neuroanatomy, the maxillary nerve (V2) is one of the three branches or divisions of the trigeminal nerve, the fifth (CN V) cranial nerve. It comprises the principal functions of sensation from the maxilla, nasal cavity, sinuses, the palate and subsequently that of the mid-face, and is intermediate, both in position and size, between the ophthalmic nerve and the mandibular nerve.

<span class="mw-page-title-main">Sphenoid sinus</span> One of the four paired paranasal sinuses

The sphenoid sinus is a paired paranasal sinus occurring within the body of the sphenoid bone. It represents one pair of the four paired paranasal sinuses. The pair of sphenoid sinuses are separated in the middle by a septum of sphenoid sinuses. Each sphenoid sinus communicates with the nasal cavity via the opening of sphenoidal sinus. The two sphenoid sinuses vary in size and shape, and are usually asymmetrical.

<span class="mw-page-title-main">Ethmoidal labyrinth</span>

The ethmoidal labyrinth or lateral mass of the ethmoid bone consists of a number of thin-walled cellular cavities, the ethmoid air cells, arranged in three groups, anterior, middle, and posterior, and interposed between two vertical plates of bone; the lateral plate forms part of the orbit, the medial plate forms part of the nasal cavity. In the disarticulated bone many of these cells are opened into, but when the bones are articulated, they are closed in at every part, except where they open into the nasal cavity.

<span class="mw-page-title-main">Posterior superior alveolar artery</span>

The posterior superior alveolar artery is a branch of the maxillary artery. It is one of two or three superior alveolar arteries. It provides arterial suply to the molar and premolar teeth, maxillary sinus and adjacent bone, and the gingiva.

<span class="mw-page-title-main">Anterior superior alveolar nerve</span>

The anterior superior alveolar nerve (or anterior superior dental nerve) is a branch of the infraorbital nerve (itself a branch of the maxillary nerve (CN V2)). It passes through the canalis sinuosus to reach and innervate upper front teeth. Through its nasal branch, it also innervates parts of the nasal cavity.

<span class="mw-page-title-main">Posterior superior alveolar nerve</span>

The posterior superior alveolar nerves (also posterior superior dental nerves or posterior superior alveolar branches) are sensory branches of the maxillary nerve (CN V2). They arise within the pterygopalatine fossa as a single trunk. They run on or in the maxilla. They provide sensory innervation to the upper molar teeth and adjacent gum, and the maxillary sinus.

<span class="mw-page-title-main">Sinus lift</span> Surgery to restore bone for tooth implants

Maxillary sinus floor augmentation is a surgical procedure which aims to increase the amount of bone in the posterior maxilla, in the area of the premolar and molar teeth, by lifting the lower Schneiderian membrane and placing a bone graft.

<span class="mw-page-title-main">Human nose</span> Feature of the human face

The human nose is the first organ of the respiratory system. It is also the principal organ in the olfactory system. The shape of the nose is determined by the nasal bones and the nasal cartilages, including the nasal septum, which separates the nostrils and divides the nasal cavity into two.

A sinus is a sac or cavity in any organ or tissue, or an abnormal cavity or passage. In common usage, "sinus" usually refers to the paranasal sinuses, which are air cavities in the cranial bones, especially those near the nose and connecting to it. Most individuals have four paired cavities located in the cranial bone or skull.

<span class="mw-page-title-main">Outline of human anatomy</span> Overview of and topical guide to human anatomy

The following outline is provided as an overview of and topical guide to human anatomy:

Antral lavage is a largely obsolete surgical procedure in which a cannula is inserted into the maxillary sinus via the inferior meatus to allow irrigation and drainage of the sinus. It is also called proof puncture, as the presence of an infection can be proven during the procedure. Upon presence of infection, it can be considered as therapeutic puncture. Often, multiple repeated lavages are subsequently required to allow for full washout of infection.

Caldwell-Luc surgery, Caldwell-Luc operation, also known as Caldwell-Luc antrostomy, and Radical antrostomy, is an operation to remove irreversibly damaged mucosa of the maxillary sinus. It is done when maxillary sinusitis is not cured by medication or other non-invasive technique. The approach is mainly from the anterior wall of the maxilla bone. It was introduced by George Caldwell (1893)and Henry Luc (1897). The maxillary sinus is entered from two separate openings, one in the canine fossa to gain access to the antrum and other in the naso antral wall for drainage.

Zygoma implants are different from conventional dental implants in that they anchor in to the zygomatic bone rather than the maxilla. They may be used when maxillary bone quality or quantity is inadequate for the placement of regular dental implants. Inadequate maxillary bone volume may be due to bone resorption as well as to pneumatization of the maxillary sinus or to a combination of both. The minimal bone height for a standard implant placement in the posterior region of the upper jaw should be about 10 mm to ensure acceptable implant survival. When there is inadequate bone available, bone grafting procedures and sinus lift procedures may be carried out to increase the volume of bone. Bone grafting procedures in the jaws have the disadvantage of prolonged treatment time, restriction of denture wear, morbidity of the donor surgical site and graft rejection.

<span class="mw-page-title-main">Oroantral fistula</span> Medical condition

Oroantral fistula (OAF) is an epithelialised oroantral communication (OAC). OAC refers to an abnormal connection between the oral cavity and antrum. The creation of an OAC is most commonly due to the extraction of a maxillary (upper) tooth closely related to the antral floor. A small OAC may heal spontaneously, but a larger OAC would require surgical closure to prevent the development of persistent OAF and chronic sinusitis.

The canalis sinuosus is a passage within the maxilla through which the anterior superior alveolar nerve, artery and vein pass. The proximal opening of the canal occurs near the mid-point of the infraorbital canal.

References

  1. 1 2 3 4 5 6 7 8 Human Anatomy, Jacobs, Elsevier, 2008, page 209-210
  2. 1 2 Morton, David A. (2019). The Big Picture: Gross Anatomy. K. Bo Foreman, Kurt H. Albertine (2nd ed.). New York. p. 246. ISBN   978-1-259-86264-9. OCLC   1044772257.{{cite book}}: CS1 maint: location missing publisher (link)
  3. 1 2 3 4 5 Bell, G.W., et al. Maxillary sinus disease: diagnosis and treatment, British Dental Journal 210, 113 - 118 (2011) at http://www.nature.com/bdj/journal/v210/n3/full/sj.bdj.2011.47.html
  4. 1 2 3 4 5 6 Sinnatamby, Chummy S. (2011). Last's Anatomy (12th ed.). Elsevier Australia. p. 376. ISBN   978-0-7295-3752-0.
  5. 1 2 3 Scuderi AJ, Harnsberger HR, Boyer RS (May 1993). "Pneumatization of the paranasal sinuses: normal features of importance to the accurate interpretation of CT scans and MR images". AJR. American Journal of Roentgenology. 160 (5): 1101–4. doi:10.2214/ajr.160.5.8470585. PMID   8470585. S2CID   7915256.
  6. ↑ Towbin, Richard; Dunbar, J. Scott (May 1982). "The paranasal sinuses in childhood". RadioGraphics. 2 (2): 253–279. doi: 10.1148/radiographics.2.2.253 . ISSN   0271-5333.
  7. 1 2 3 Illustrated Anatomy of the Head and Neck, Fehrenbach and Herring, Elsevier, 2012, page 67
  8. ↑ Kiran Kumar Krishanappa, Salian; Eachempati, Prashanti; Kumbargere Nagraj, Sumanth; Shetty, Naresh Yedthare; Moe, Soe; Aggarwal, Himanshi; Mathew, Rebecca J (2018-08-16). "Interventions for treating oro-antral communications and fistulae due to dental procedures". The Cochrane Database of Systematic Reviews. 2018 (8): CD011784. doi:10.1002/14651858.CD011784.pub3. ISSN   1469-493X. PMC   6513579 . PMID   30113083.
  9. 1 2 Regimantas Simuntis; Ričardas Kubilius; Saulius Vaitkus (2014). "Odontogenic maxillary sinusitis: A review" (PDF). Stomatologija, Baltic Dental and Maxillofacial Journal.
  10. ↑ Franco-Carro, B.; Barona-Dorado, C.; Martínez-González, M.-J.-S.; Rubio-Alonso, L.-J.; Martínez-González, J.-M. (2011-08-01). "Meta-analytic study on the frequency and treatment of oral antral communications". Medicina Oral, Patologia Oral y Cirugia Bucal. 16 (5): e682–687. doi: 10.4317/medoral.17058 . ISSN   1698-6946. PMID   20711106.
  11. 1 2 3 4 5 Khandelwal, Pulkit; Hajira, Neha (January 2017). "Management of Oro-antral Communication and Fistula: Various Surgical Options". World Journal of Plastic Surgery. 6 (1): 3–8. ISSN   2228-7914. PMC   5339603 . PMID   28289607.
  12. ↑ Merriam-Webster's Medical Desk Dictionary Revised Ed. 2002, pg 49.
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