max sinus

Question 1

what is management if root tip is trapped below antrum lining

Answer 1

• raise buccal flap
• enlarge socket
• remove root
• close with buccal flap
• standard sinus precautions

Question 2

mx if root tip penetrated into sinus

Answer 2

• OAP
• caldwell luc procedure

Question 3

immediate and delayed signs of OAP after exo

Answer 3

immediate
- direct visualisation of sinus using mirror
- misting of mirror or bubbles at socket when patient exhales through nose
- hollow whistling suction sound
- water enters nose on irrigation of socket
- post op epistaxis

delayed
- symptoms of sinusitis
- unilateral nasal congestion
- unilateral purulent nasal discharge
- water goes into nose when drinking
- change in voice/ air escaping from nose when speaking

Question 4

how to manage moderate OAP

Answer 4

2-6mm

• gelfoam/surgicel and secure with figure of 8 suture
• sinus precautions for 1-2 weeks (open mouth when sneezing, no blowing nose, no swimming, no smokin, no straws)
• antibiotics (usually amox)
• decongestants
• return if OAC symptoms develop

Question 5

how to manage large OAP

Answer 5

> 4mm

• surgical closure required (buccal advancement flap, palatal rotation flap, buccal fat pad)
• sinus precautions
• antibotics
• decongestants

Question 6

how to manage OAF

Answer 6

• eliminate sinusitis before closing
• daily antral irrigation with 15-20ml warm saline, patient leans forward, repeat until liquid is clear then 2 more days
• medication for sinusitis (antibiotics, painkillers, decongestants)
• splint can be constructed to cover and protect socket
• surgical closure of OAF (techniques are the same as closure of large OAP but fistulous tract must be excised first)

Question 7

how to prevent OAP

Answer 7

• if radiographs show a pneumatised sinus/ widely divergent long roots, can consider doing an open extraction and sectioning the tooth to remove one root at a time
• warn patient of possibility of OAC as patients who are flying within the week of surgery may choose to defer it
• when fractured root fragment is stuck in socket, to retrieve via closed technique only if the top of the root can be visualised. if not should raise flap and remove it surgically

Question 8

defn of sinusitis, and the difference between acute and chronic

Answer 8

sinusitis is the inflammation of the mucous membrane that lines the sinuses caused by infection (bacteria/virus) or non infectious means (allergy)

acute sinusitis lasts for less than 3 weeks while chronic sinusitis lasts for 3 months or more

Question 9

how to differentiate between bacterial or viral sinusitis

Answer 9

viral sinusitis typically lasts 20 days, so symptoms that are longer are typically suggestive of bacterial sinusitis

Question 10

possible complications of maxillary sinusitis

Answer 10

if the infection spreads to other paranasal sinuses, can cause:

• cavernous sinus thrombosis
• meningitis
• osteomyelitis (frontal sinus)

Question 11

steps to diagnose odontogenic maxillary sinusitis

Answer 11

1) hx taking
- s&s
- duration
- hx of exo, endo, surgery

2) clinical exam

• inspect: swelling or erythema at cheek area, check for any potential odontogenic aetiology
• palpate: lateral walls of sinus overlying cheekbones for any tenderness. intraorally, palpate lateral surface of maxilla between canine fossa and ZMC
• percussion: maxillary posterior teeth
• transillumination: compare transmission of light of L and R max sinus in a dark room

3) radiographic examination
will be able to see
- partial or total opacity in antral cavity on OPG/CBCT
- on CBCT might be able to see thickening of antral walls
- fluid

4) dx by inclusion of dental pathology

Question 12

what AB to give for odontogenic maxillary sinusitis

Answer 12

1) Augmentin 500mg BD 5/7 + Metro 400mg TDS 5/7

2) for px with penicillin allergy, use respiratory fluoroquinolones ie cipro combined with metronidazole

Question 13

how long should we prescribe decongestants for

Answer 13

not more than 5 days as it induces vasoconstriction to reduce secretion

Question 14

what will we see in water’s view when there is maxillary sinusitis

Answer 14

• radiopacity
• removes the superimposition of the mastoid process

Question 15

how to manage small OAP

Answer 15

<2mm

• gauze pressure for hemostasis
• advise sinus precautions for 10-14 days
• follow up within 48-72 hours or earlier if symptomatic
• dont need to pack gelfoam

Question 16

what is the rationale of prescribing AB for OAP

Answer 16

prophylactic measure to prevent entry of oral bacteria into sinus (give 2 week course)

Question 17

what decongestants to prescribe

Answer 17

• topical pseudoephedrine, phenylephrine, oxymetazoline

all 5 day course

Question 18

what are some mucolytics to prescribe

Answer 18

flumucil (components are acetylcysteine, bromhexine, carbocysteine)w

Question 19

what is an example of intra nasal steroid

Answer 19

fluticasone

Question 20

when can we STO after surgery of sinus eg to close a large OAP?

Answer 20

must be 10 days or more because sinus mucosa takes 10-14 days to form

Question 21

why do we have to excise fistulous tract completely in OAF before closing

Answer 21

because remnant epithelial lining may proliferate to reform tract

Question 22

what are the 4 buttresses of the face that we can see from waters view

Answer 22

• supraorbital ridge (most superior)
• inferior orbital, nasal bones
• zygomaticomaxillary buttress
• inferior border of mandible