Surgical anatomy of nose and maxilliary sinus.pptx [autosaved]

SURGICAL ANATOMY OF NOSE &
MAXILLARY SINUS
Guided By: Dr. Sachin Kumar, Prepared By: Dr. Monalisa, MDS- 1st Year, Department of Oral & Maxillofacial Surgery, School Of Dental Sciences, Sharda University

TABLE OF CONTENT
1.0 Nose
External Nose
Nasal Cavity
Nasal Septum
Lateral Wall of nose
2.0 Maxillary Sinus
3.0 References

1.0 NOSE

1.1 INTRODUCTION
• The External nose :
• Is a pyramidal projection of face
• Performs two functions.
• Respiratory passage and organ of
smell
• Acts as an air conditioner where the
inspired air is warmed, moistened
and cleansed

1.2 NASAL CAVITY
• Extends from external nares or nostrils to the posterior nasal apertures
• Subdivided into right and left halves by nasal septum
• Height-5cm,Length-5-7cm,Width-1.5cm(near floor)1-2mm(near roof)
• Anterior slope-nasal part of frontal bone,Nasal bone,Nasal cartilage
• Posterior slope-inferior surface of body of sphenoid
• Floor-palatine process of maxilla & horizontal plate of palatine bone
• Roof-Crista galli,Cribriform plate,Body of sphenoid

1.2 NASAL CAVITY CONT.

1.3 NASAL SEPTUM
• Osseocartilagenous partition
• Covered by mucous membrane and forms medial wall of
both nasal cavity
• Composed of five parts:
• Perpendicular plate of ethmoid bone
• Vomer bone
• Crest of maxillary bone
• Crest of palatine bone
• Cartilage of septum
• Lower margin of the septum is called the COLUMELLA
Fig: Sagittal View Of Nasal Septum

1.3 NASAL SEPTUM cont.
• Rarely strictly median
• Central part usually deflected to
one or other side
• Deflection is produced by
overgrowth of one or more of
the constituent parts

1.4 ARTERIAL & NERVE SUPPLY- NASAL SEPTUM
• Arterial supply
• Anterior and posterior ethmoidal
artery
• Superior labial branch of facial artery
• Sphenopalatine artey
• Greater palatine artery
• Nerve supply
• Internal nasal branches of anterior
ethmoidal nerve
• Anterior superior alveolar nerve
• Medial posterior superior nasal
branch of pterygopalatine ganglion
• Nasopalatine branch of
pterygopalatine ganglion(main nerve)

1.5 LYMPHATIC & VENOUS DRAINAGE- NASAL SEPTUM
• Lymphatic drainage
• Anterior half-submandibular nodes
• Posterior half-retropharyngeal and
deep cervical nodes
• Venous drainage
• Anteriorly –facial vein
• Posteriorly-through sphenopalatine
vein to pterygoid venous plexus

1.6 LATERAL WALL OF NOSE
• Irregular owing to the presence of three shelf like
bony projections called CONCHAE.
• Meatuses-Spaces separating the conchae
• Separates nose:
• From the orbit above
• From maxillary sinus below
• From lacrimal groove & nasolacrimal canal in
front
• Subdivision
• Vestibule-small depressed area in anterior part
• Atrium-middle part
• Conchae-posterior part

1.6 LATERAL WALL OF NOSE cont.
• Skeleton is partly bony,partly cartilaginous and partly made up of soft tissues
• Bony part is formed by following bones
Nasal Inferior nasal conchae
Frontal process of maxilla Perpendicular plate of palatine bone together with its orbital and sphenoidal processes
Lacrimal Medial pterygoid plate
Labyrinth of ethmoid with superior and middle conchae

• Cartilagenous part is formed by:
• Superior nasal cartilage
• Inferior nasal cartilage
• 3-4 small cartilages of ala
• Cuticular lower part is formed by
Fibrofatty tissue covered with
skin

1.7 CONCHAE & MEATUSES
• Conchae
• Superior-projection from medial surface of ethmoidal labyrinth.
• SMALLEST
• Middle-projection from medial surface of ethmoidal labyrinth
• Inferior –independent bone
• Meatuses
• Superior -lies below the superior conchae
• Shortest & shallowest
• Middle -lies underneath the middle conchae
• Inferior-lies underneath inferior conchae
• LARGEST

1.7 CONCHAE & MEATUSES …CONT

1.8 ARTERIAL & NERVE SUPPLY
• Arterial supply
• Anterior ethmoidal artery
• Facial artery
• Sphenopalatine artery
• Nerve Supply
• General sensory
• Anterior ethmoidal nerve
• Lateral posterior superior nasal branch
• Anterior palatine branch
• Special sensory-distributed to the upper
part of the lateral wall just below
cribriform plate

1.9 VENOUS & LYMPHATIC DRAINAGE
• Venous drainage
• Anteriorly into facial vein
• Posteriorly into pharyngeal plexus of veins
• From middle part to pterygoid plexus of vein
• Lymphatic drainage
• From anterior wall-submandibular nodes
• From posterior half-retropharyngeal & upper deep
cervical nodes

2.0 Maxillary Sinus

2.1 INTRODUCTION
• Pneumatic space lodged in the body of maxilla.
• Described by Nathenial Highmore (1651)
• Also known as antrum of Highmore
• 2 in number
• Largest paranasal sinus
• Vol:15-30 ml
• Dimensions (Turner, 1902)
• Anteroposterior: 3.5cm
• Height: 3.2cm
• Width: 2.5cm

2.2 EMBRYOLOGY
First sinus to develop embryonically(17th day of gestation)
Begin as mucosal invagination that grows laterally from middle
meatus of nasal cavity
At birth-less than a centimeter
After birth-expands by pneumatization(biphasic growth during first
3yrs & again from 7-12yrs)
• Early stages it is high in maxilla
• later gradually grows downwards by process of pneumatization

2.3 Pneumatization with age
At birth:begins medial to the orbit & its
dimensions are largest anteroposteriorly
At 2 years:continues inferiorly below the medial
orbit and continues to pneumatize laterally
By 4 years :sinus reaches the infraorbital canal
and continues laterally
By 9 years :inferior growth reaches the region of
hard palate

2.4 ANATOMY
• Base - lateral wall of nose.
• Apex - zygomatic process of maxilla.
• Roof - floor of orbit traversed by the
infraorbital canal.
• Floor – Base of the maxillary alveolar
process.
• Anterior wall-facial surface of maxilla
• Posterior wall-separates sinus from
infratemporal and pterygopalatine fossa

2.5Anatomic relationship with teeth
• Distance from the sinus floor to root tips of teeth is longest for
first premolar &shortest for second molar distobuccal root tip
• Septa
• Strut of bone that is atleast 2.5 mm in height
• Primary septae:found between the roots of second premolar &
first molar and roots of first & second molar,& distal to the roots
of third molar
• Secondary septae:occur as a result of pneumatization after
dental extraction
• Septae in edentulous regions tend to be larger
• The presence of septae is pertinent for sinus lift
procedures,because they complicate the process of luxating the
boney window to expose the sinus & increase the likelihood of
sinus membrane perforation

2.6 Ostium of maxillary sinus
• Opening that forms drainage channel of
maxillary sinus
• Size and numbers of maxillary sinus ostia are
variable
• Average length of sinus ostium is 5.55mm
• Oriented inferolaterally from the infundibulum
to the antrum to drain the maxillary sinus into
hiatus semilunaris
• Accessory ostium (in 16% of individuals) typically
exists only as an opening and not a canal with an
average length of 1.5mm

2.7 PHYSIOLOGY & FUNCTIONS OF SINUS
• Physiology
• Lined by respiratory epithelium
• Mucous secreting Pseudostratified ciliated columnar epithelium
• Schneiderian membrane(mucous membrane,covers the inner part of maxillary sinus)
• It has mucociliary mechanism
• Cilia moves the mucous and debris towards ostium and discharged in middle meatus
• Functions
• Impart resonance to voice
• Increase surface area and lighten skull
• Moisten and warm inspired air
• Filters debris from inspired air
• Gives air padding to provide thermal insulation to adjacent important tissues

2.8 ARTERIAL & NERVE SUPPLY, VENOUS & LYMPHATIC DRAINAGE
• Arterial supply
• Facial artery
• Infraorbital artery
• Venous drainage
• Facial Vein
• Pterygoid plexus of vein
• Lymphatic Drainage
• Submandibular Nodes
• Nerve Supply
• Middle superior alveolar nerve
• Posterior superior alveolar nerve

2.9 CLINICAL EXAMINATION
Tapping of lateral walls of Sinus externally over
the prominence of cheek bone
Palpation Intraorally on lateral surface of maxillary
both canine fossa & zygomatic buttress
Affected Sinuses – Tender to gentle tapping /
Palpation
Transillumination

2.10 RADIOLOGY OF MAXILLARY SINUS
• EXTRAORAL VIEWS
• OCCIPITOMENTAL/WATERS
• LATERAL SKULL
• SUBMENTOVERTEX
• ORTHOPANTOMOGRAPHY
• CT SCAN
• INTRAORAL VIEWS
• OCCLUSAL
• LATERAL OCCLUSAL
• PERIAPICAL

2.10 RADIOLOGY OF MAXILLARY SINUS CONT.
OrthopantomographOccipitomental or waters view

CT- SINUS - CORONAL VIEWCT- SINUS –AXIALVIEWLateral Skull

Periapical viewOcclusal view

2.11 APPLIED SURGICAL ANATOMY
Relation of root apices with the floor of the sinus
Foreign bodies in the sinus
Infections of sinus
Oro-antral communication
Tumors associated with maxillary sinus
• Implant placement

2.11 OROANTRAL FISTULA
• Oroantral fistula is a pathological communication between
oral cavity and maxillary sinus.
• MANAGEMENT
• Less than 2mm heals spontaneously
• Larger than 3 mm requires surgical closure
• Ideal treatment :immediate surgery followed
by Antibiotic prophylaxis
• Do gentle packing of the socket with wet gauze to control
bleeding from the socket and for antral bleeding sinus is
packed with roller gauze.
• Do not probe the sinus with sharp instruments
• Do not curette the socket
• Do not ask the patient to blow the nose
• Prescribe antibiotics and other symptomatic treatment

2.12 SURGICAL PROCEDURES INVOLVING MAXILLARY SINUS
• Caldwell-Luc Operation
• Intra nasal antrostomy
• Functional Endoscopic Sinus Surgery
• Sinus Lift Procedure
• Mid Face fractures

2.13 CALDWELL LUC SINUSOTOMY(By George Caldwell
(1893) & Henry Luc (1897)
• The surgical procedure can be performed under LA. Or GA.
• A semilunar incision is placed in the buccal vestibule from canine to second molar.
• A mucoperiosteal flap is elevated till infraorbital ridge.
• A round bony cut is marked over the canine fossa using a round bur
• Window is created and bone is removed using rongeur
• Then pus is sucked away from the sinus and thorough irrigation is carried out.
• Inspection and removal of foreign body from the sinus can be done at this stage.
• Antral cavity packed with iodoform ribbon gauze.
• The incision is closed with 3-0 silk.
• Pack removal on 5 th day

2.14 DENKER’S APPROACH
Modification of Caldwell luc surgery
• Along with the Caldwell Luc surgery a slit of
bone is removed from the anterior bony angle
of the antrum right up to the lateral nasal
aperture to render continuous free
unimpeded drainage of sinus from nasal
cavity and canine fossa

REFERENCES
• B D Chourasia , Text book of Anatomy
• Contemporary oral and maxillofacial surgery, Peterson
• Fonseca text book of oral and maxillofacial surgery
• Treatment of Oro antral Fistula using Bone press fit technique. American association of oral
and maxillofacial surgeon 2012
• Gray’s Anatomy – Third Edition
• Surgical Anatomy Of the Nasal Cavity and Paranasal Sinuses- Ogle et al.
• Clinical Anatomy of the Maxillary Sinus: Application to Sinus Floor Augmentation: Iwanaga et
al
• Maxillary sinus augmentation: Tarun et al.

THE END
THANK YOU

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