Dr. Esam Ahmad Z. Omar BDS, MSc-OMFS, FFDRCSI

Size: px

Start display at page:

Download "Dr. Esam Ahmad Z. Omar BDS, MSc-OMFS, FFDRCSI"

Samson Bell
5 years ago
Views:

Anatomy of the Maxillary Sinus Dr. Esam Ahmad Z.

Allergy: Allergic Naso-Sinusitis B) infections: a) Acute b) Chronic 2) Tumours Diseases of Sinuses Acute Infections Most cases of acute maxillary sinusitis are

In about 10% of cases the infection is dental in origin as in: 1) Apical abscess 2) Dental extraction 3) Oro-antral fistula Occasionally infection follow the

1 Anatomy of the Maxillary Sinus Dr. Esam Ahmad Z. Omar BDS, MSc-OMFS, FFDRCSI Assistant Professor & Consultant Oral&Maxillofacial Surgeon Anatomy of the Maxillary Sinus Diseases of Sinuses 1) Inflammatory: A) Allergy: Allergic Naso-Sinusitis B) infections: a) Acute b) Chronic 2) Tumours Diseases of Sinuses Acute Infections Most cases of acute maxillary sinusitis are secondary to: 1) Common cold 2) Influenza 3) Measles, whooping cough, etc. In about 10% of cases the infection is dental in origin as in: 1) Apical abscess 2) Dental extraction 3) Oro-antral fistula Occasionally infection follow the entry of infected materials as in: 1) Diving-water is forced though the ostium 2) Fractures 3) Gunshot wound-contaminated Diseases of Sinuses Acute Infections Signs and symptoms: 1) Pain over the sinus area 2) referred to adjacent area 3) the pain is throbbing in nature 4) Nasal obstruction Pathology: 1) Pneumococcus 2) Haemophilus influenzae 3) Staphylococcus pyogenes 1

Diseases of Sinuses Acute Infections Empyema of the antrum: When the ostium is obstructed by oedema, the antrum become filled with pus under pressure.

antrum Diseases of Sinuses Acute Infections Treatment: 1) Bed rest 2) An appropriate antibiotic should be started 3) Nasal vasoconstrictor drop will aid to drain the sinus 4) Analgesics In the most

2 Diseases of Sinuses Acute Infections Empyema of the antrum: When the ostium is obstructed by oedema, the antrum become filled with pus under pressure. Signs and symptoms: 1) Pyrexia is usually present 2) Tenderness over the antrum 3) Mucopus in the nose or naso-pharynx 4) there may be oro-antral fistula 5) X-ray show opacity or fluid level in the antrum Diseases of Sinuses Acute Infections Treatment: 1) Bed rest 2) An appropriate antibiotic should be started 3) Nasal vasoconstrictor drop will aid to drain the sinus 4) Analgesics In the most cases, resolution of acute maxillary sinusitis will occur, but occasionally antral wash out will be necessary to remove any residual debris. It should not preformed in the acute phase. Diseases of Sinuses Chronic Infections Predisposing factors: 1) Nasal Allergy. Polyp 2) Oro-Antral Fistula 3) gross septal deformities 25% of patients with nasal polyps have chronic sinusitis Diseases of Sinuses Chronic Infections Signs and Symptoms: Patients with chronic sinusitis usually have few symptoms 1) may be nasal obstructions 2) Usually Nasal and post nasal discharge 3) mucopus in the nose or naso-pharynx 4) Nasal mucosal congestion 5) X-ray shows fluid level, opacity, or mucosal thickening Diseases of Sinuses Intra-nasal antrostomy Chronic Infections Treatment: Medication like antibiotic, nasal drop and analgesic may produce resolution but recurrent is high 1) Predisposing factors should be will treated 2) Antral puncture and lavage a) Intra-nasal antrostomy- b) Caldwell-luc operation c) antral endoscopy 2

3 Caldwell-luc operation antral endoscopy Oro-antral Fistula Oro-antral Fistula( Buccal Extended Flap) Closure of fistula: 1) Refresh the fistula wall 2) use a local flap for closure There are two type of local flape can be used: a) Palatal rotation flap b) Buccal extension flap Oro-antral Fistula( Palatal Rotation Flap) Complications of long standing Sinusitis Otitis media: the most common sources are the maxillary sinus, adenoid, tonsils, 3

Complications of long standing Sinusitis

Cavernous sinus septic thrombosis Carcinoma of

Maxillary Sinus Carcinoma Primary tumours of

tumours of Maxillary Alveolus/palate/upper

Esam Ahmad Omar BDS, MSc-OMFS-, FFDRCSI 4

4 Complications of long standing Sinusitis Complications of long standing Sinusitis Complications of long standing Sinusitis and Acute episodes Complications of long standing Sinusitis and Acute episodes Cavernous sinus septic thrombosis Carcinoma of the Maxillary Sinus Sites of Origin of Maxillary Sinus Carcinoma Primary tumours of Nasal Cavity & Paranasal sinuses Primary tumours of Maxillary Alveolus/palate/upper sulcus Dr. Esam Ahmad Omar BDS, MSc-OMFS-, FFDRCSI 4

Distribution of Sites for Primary Tumours of Nasal Cavity & Paranasal Sinuses

Papilloma Osteoma Chondroma Fibrous dysplasia Leiomyoma Schwannoma Haemangioma

Malignant melanoma Histological Distribution of Malignant Tumours of Nasal Cavity &

5 Distribution of Sites for Primary Tumours of Nasal Cavity & Paranasal Sinuses Histological Distribution of Tumours Benign Sinonasal Tumours Intermediate Tumors Papilloma Osteoma Chondroma Fibrous dysplasia Leiomyoma Schwannoma Haemangioma Papilloma Haemangiopericytoma Meningioma Oncocytoma Malignant Sinonasal Tumours BCC Malignant melanoma Histological Distribution of Malignant Tumours of Nasal Cavity & Paranasal Sinuses SCC Minor salivary gland neoplasms Sarcomas Adenocarcinoma Lymphoma Neurogenic tumours 5

6 SCC Risk Factors for Sinonasal Cancer 60% - Maxillary sinus 30% - Nasal cavity 10% - Ethmoid sinuses 1% - Sphenoid/Frontal sinus Woodworking dust Nickel refining Textile workers Isopropyl oil Snuff HPV M:F 2:1 Mean age 55 yrs 6

7 Ohngren s Line Routes of Spread of Maxillary Sinus Carcinoma Diagnosis of Maxillary Sinus Carcinoma History Examination Imaging Symptoms of Early Maxillary Sinus Carcinoma Often no early symptoms Sinusitis Swelling of upper gum Biopsy 7

Symptoms of Locally Advanced Maxillary Sinus Carcinoma Symptoms of Advanced Maxillary

in hard palate/gum/upper sulcus Trismus Swelling of cheek Nasal Obstruction

Transnasal needle biposy Endoscopic CT- axial - coronal - bone windows - 3-D MRI

meatus Invasion of skin, post wall, orbital floor, anterior ethmoids Invasion orbital

8 Symptoms of Locally Advanced Maxillary Sinus Carcinoma Symptoms of Advanced Maxillary Sinus Carcinoma Anaesthesia of Infraorbital nerve Diplopia Proptosis Epistaxis Mass in hard palate/gum/upper sulcus Trismus Swelling of cheek Nasal Obstruction Histological Diagnosis Open biopsy Radiographic Evaluation Plain radiographs Transnasal needle biposy Endoscopic CT- axial - coronal - bone windows - 3-D MRI Staging for Antral & Ethmoid SCC Limited to antral mucosa T1 Erosion of palate/middle meatus Invasion of skin, post wall, orbital floor, anterior ethmoids Invasion orbital contents, cribriform plate, post ethmoids/sphenoid, nasopharynx, soft palate, pterygomaxillary space T2 T3 T4 8

Stage Distribution of SCC of the Maxilla Selection of Treatment Surgery alone: All benign tumours Early stage malignant tumours Surgery & RT: Advanced malignant

Distant metastases Pt refuses surgery Pre operative Preparation Multidisciplinary Clinic Dental Assessment Hygienist Speech Therapist Dental Impressions

9 Stage Distribution of SCC of the Maxilla Selection of Treatment Surgery alone: All benign tumours Early stage malignant tumours Surgery & RT: Advanced malignant tumours Advanced Unresectable Tumours: Chemo/RT Malignant Lymphoma: Chemo/RT Causes of Incurability Widespread intracranial involvement Poor surgical risk Distant metastases Pt refuses surgery Pre operative Preparation Multidisciplinary Clinic Dental Assessment Hygienist Speech Therapist Dental Impressions Surgical Approaches Facial Incisions -Transnasal -Transoral -Transpalatal -Lateral Rhinotomy -Midface Degloving -Weber-Ferguson -Le Fort 1 -Combined Craniofacial approach 9

$Fort 1 Downfracture$ Upper Cheek Flap

10 Midface Degloving Le Fort 1 Downfracture Upper Cheek Flap Resection Procedures -Partial maxillectomy -Subtotal maxillectomy -Medial maxillectomy -Total maxillectomy -Radical maxillectomy & orbital exenteration -Anterior craniofacial resection Medial Maxillectomy 10

11 Total Maxillectomy 11

12 12

13 Radiotherapy Adjuvant treatment with surgery Palliative Cataracts, blindness, trismus, Scar retraction, xerostomia Side effects 13

14 Reconstructive Options Factors to consider: Function Speech, eating, swallowing Psychological Cosmetic Reconstructive Options Obturator No tissue SSG Local Flap Tongue Buccinator Nasolabial Forehead Iliac bone Regional Flap Temporalis Pectoralis Buccal Fat Pad Free Flap Rectus Radial Forearm Scapular Fibular Lat Dorsi DCIA Maxillectomy-to reconstruct or obturate? Results of a UK survey of oral & maxillofacial surgeons Ali et al. BJOMS 1995 Conventional Obturator 123 surgeons 1-5 cases/year 62% - use obturator 38% - reconstruct surgically but in 10% of only cases 14

Advantages Obturators Disadvantages Monitor recurrence Soft tissue support No donor site morbidity Oro-nasal regurgitation Bulk Frequent adjustments Hygiene problems Pre-Prosthetic Planning Preserve

Pre-Prosthetic Planning Immediate Surgical Reconstruction Disadvantages Advantages Remove inferior turbinate to prevent interference Reflect palatal mucosa over medial margin of resected palate for

15 Advantages Obturators Disadvantages Monitor recurrence Soft tissue support No donor site morbidity Oro-nasal regurgitation Bulk Frequent adjustments Hygiene problems Pre-Prosthetic Planning Preserve as much hard palate as possible Keep tooth adjacent to maxillary defect as an abutment Pre-Prosthetic Planning Split skin graft provides better tissue surface Scar band assists retention of obturator Pre-Prosthetic Planning Immediate Surgical Reconstruction Disadvantages Advantages Remove inferior turbinate to prevent interference Reflect palatal mucosa over medial margin of resected palate for tissue coverage If > 50% of soft palate is resected consider removal of remainder of residual palate Prolonged op time Donor site morbidity Excessive bulk Unable to monitor recurrence? Avoids problems assoc with obturators Superior cosmetic and functional outcome 15

16 Objectives of Surgical Reconstruction Pedicled Local Flap Buccal Fat Pad Consistently obtain a healing wound Restore palatal competence and function Obliterate the maxillary defect Restore facial contour Support the orbit or fill the orbital cavity Cover Plate Inserted Healed Buccal Fat Pad Reconstruction 16

17 Temporalis Flap Palatal Island Flap Radial Forearm Free Flap Scapular Flap DCIA 17

18 Rectus Abdominis Flap Latissimus Dorsi Flap Implant Retained Prosthesis Implant Retained Prostheses Tranzygomatic Implants Algorithm for Maxillectomy Defect Reconstruction 18

19 Results of Treatment 5 yr Survival 5-Year Survival by stage: SCC of maxilla Patterns of Failure: SCC of Maxilla The Royal College of Surgeons The End 19

MALIGNANT TUMOURS OF THE JAWS

MALIGNANT TUMOURS OF THE JAWS MALIGNANT TUMOURS OF THE JAWS Squamous cell carcinoma Osteogenic sarcoma Chondrosarcoma Fibrosarcoma Malignant lymphomas (incl. Burkitt s) Multiple myeloma Ameloblastoma Secondary