Paranasal

sinuses
By: Atheer AlSabri
Khalil AlSaffar

Pseudo stratified columnar

ciliated epithelium

Ethmoid
sinuses
Superior
meatus
Middle
Meatus

A coronal cross section diagram of the

Frontal
sinuses
Fronto-nasal
duct

A coronal cross section diagram of the

Sphenoid
sinuses

Body of the
sphenoid bone
Sphenoethmoi
dal recess

Sagittal CT image showing the sphenoid sinus (SpS)

with sinus ostium (*) and arrow demonstrating the
sphenoethmoidal recess (SER). (PE: posterior ethmois

Maxillary
sinuses
Infraorbital
recess
Zygomatic
recess

Alveolar
recess

Semilunar
hiatus

A coronal cross section diagram of the

Fucntion
Heating and humidification
Reduction of cranial weight
Voice resonation
Evolutionary unwanted
space

Imaging the
maxillary sinus

Periapical radiograph
Highest detail/
resolution
Only floor can be
viewed

Periapical radiograph
Nasal fossa
Septu
m
Zygomatic
proccess

Periapical radiograph
Soft radiolucent
neurovascular canals
These are bony nodules, that
appear to be well defined and
blend at certain points,
homogenous and showing
trabeculation.

Waters view
X-ray
receptor
or film

Occipitomental
radiograph
X-ray
tube

Head tilted
back 37
degrees

Frontal
sinuses
Superior
maxillary
border
Maxillary
sinus
Zygomatic
bone
Zygomatic
arch

Lateral cephalometric
Superimposition of the left and right sides.
The structures closer to the image receptor
appear less magnified.
Not used as a diagnositic tool.

Lateral cephalometric
Sphenoid sinus
Ethmoid sinus
Maxillary sinus
Floor of the orbit

Pterygomandibular fissu
Zygomatic body and
process
Hard palate

This is lateral skull radiograph of the mucous retention

in the maxillary sinus

PANORAMIC RADIOGRAPH
Full continous border
Super imposition of the zygoma
Compare the left and right sinuses for
abnormalities.
Usually asymmetrical

Infraorbital
canal
Zygomatic
body

Computed tomography
Slit like beam of rays.
Receptor encircles the patient
Produces images which resembles slices of
the patient.
Contraindications: Acute inflammatory
swelling

CT Scan a large mass was seen in the

MAGNETIC RESONANCE
IMAGING
Rapidly changing magnetic fields.
Physical and biochemical properties of
the tissue examined.
Differentiating between inflammatory
and tumor tissue.

Right maxillary mucocele eroding superior wall of the

sinus causing eye proptosis and cheek swelling.

CT versus MRI
ADVANTAGES
OF CT

ADVANTAGES
OF MRI

Better bony
detail

Superior soft
tissue
discrimination

Less expensive

Multiplanar

More readily
available.

No radiation

Dental artifacts

Vascular anatomy

Intrinsic
diseases of the
maxillary sinus

Mucositis
Definition: increase in thickness of lining
mucosa 10 to 15 times due to infection or
allergic process.

Clinical features:
Asymptomatic
unrecognized by
patient and are
discovered only
incidentally on a
radiograph.

Radiographic
findings:
Thickened mucosa is
detectable in the
radiogrph as a
noncorticated band
notice more radiopaque
than air filled sinus .

Locally thickened mucosa is seen as a

noncorticated, radiopaque band that follows
the contour of the sinus floor.

Sinusiti
s
Definition: Generalize inflammation of paranasal sinus
mucosa due to allergen, bacteria, or viral and there Is
classification that divide sinusitis into three subtypes
based on the time :Acute sinusitis:
present for less 2
weeks.

Subacute
sinusitis :
from 2 weeks
to 3 months

Chronic
sinusitis:
present for
more than 3
months.

Clinical features
Acute sinusitis:
Can cause clear nasal discharge or pharyngeal
drainage and the patient may complain of pain and
tenderness to pressure or swelling over the involved
sinus associated with fever, chills, malaise and
elevated leukocyte. The pain may also referred to the
premolar and molar teeth on the affected side.
Chronic sinusitis:
No external sign occur. Chronic sinusitis associated
with anatomic derangements that inhibit the
outeflow of mucus and also associated with allergic,
asthma, cyctic fibrosis and dental infection.

Radiographic
feature
Thickening of sinus mucosa and accumulation of
secretions that reduce air content of the sinus that
cause increase radiopacity. the most common
radiopaque patterns that occur in the Waters view
are localized mucosal thickening along sinus floor and
generalized thickening of the mucosal lining around
the entire wall of the sinus.

Sinusitis results in generalised thickening of the mucosa,

which makes the internal structure of the maxillary sinus
more radiopaque.
Figure A: Internal radiopacity. Figure B: Normal sinus.

Retention
pseudocyst
Definition: Blockage of the secretory ducts of
seromucous gland in the sinus mucosa.
Clinical features
The retention pseudocyst
rarely cause any sign or
symptoms, some clinical
features show nasal
obstruction and postnasal
discharge.

Radiographic
features
Pseudocyst
may occur
bilaterally. Occasionally
more than one
pseudocysts may form in
sinus and some may form
on the lateral walls.

This is lateral skull radiograph of the mucous retention

psuedocyst in the maxillary sinus

Polyps
Definition: The thickened mucous membrane of a
chronically inflamed sinus frequently forms into irregular
folds.

Clinical features:
Cause displacement or
destruction of bone and
can cause destruction of
the medial wall of the
orbit.

Radiographic
features:
Polyp usually occurs with
a thickened mucous
membrane lining.

This is CT, Coronal image with arrow pointing to maxillary sinus polyp. Often on
imaging a polyp and mucus retention cyst cannot be differentiated, but is usually of
little clinical consequence.

Antrolith
Definition:
Antroliths occur within the maxillary sinus and result of
deposition of mineral salts such as calcium phosphate,
calcium carbonate, and magnesium around a nidus.
Clinical features:
The smaller antrolith are
asymptomatic and usually
are discovered as
incidental findings on the
radiographic examination
and the patient associated
sinusitis, blood stained
nasal discharge, nasal

Radiographic
features:
Antrolith are well
defined and may have a
smooth or irregular
shape.

A lateral maxillary occlusal film that reveals the presence of a radiopaque

antrolith. Note that the antrolith is positioned above the sinus floor.

Mucocele
Definition : Mucocele is an expanding, destructive lesion
that result from blocked sinus ostium.
Clinical features:

Radiographic features:

Fullness in the cheek and

the area may swell and it
may cause loosening of
the posterior teeth in the
area and also can cause
diplopia.

About 90% of mucoceles

occur in the ethmoidal and
frontal sinus and rare in the
maxillary and sphenoid
sinuses and the shape of
sinus change into more
circular shape as the
mucocele enlarges.

This is maxillary sinus on the right side is completely obliterated by a mucocele and
these mucoclel cystic like multiloculated mass and also This mucoclele extends fills
the upper nasal cavity on the right and displacing the orbital contents.

Benign neoplasms of
the paranasal sinuses
Epithelial papilloma
Osteoma

Epithelial papilloma
Definition: The epithelial papilloma is rare neoplasm of
respiratory epithelium that occur in the nasal cavity and
paranasal sinuses. It occur manly in the men.
Clinical features :

Radiographic features:

Unilateral nasal
obstruction, nasal
discharge, pain and the
patient may have
complained of recurring
sinusitis for years. The
epithelial papilloma
relatively rare and has

Its appears as an isolated

polyp in the nose or sinus.
This neoplasm appears as a
homogenous radiopaque
mass of soft tissue density.

A. A recurrent right maxillary

sinus inverted papilloma. The
entire mass in the maxillary
sinus is homogeneous by CT
scan.

B. MRI scan of the same patient

demonstrating the delineation
between retained secretions
and inverted papilloma.
However, the MRI does not
define the site of attachment

Osteoma
Definition: Osteoma is the most common of the
mesenchymal neoplasm in paranasal sinuses.
Clinical features:
It is almost twice as common in the males as females and
more common in the second, third and fourth decades.
Most are slow growing and asymptomatic and when
symptoms occur they are result of obstruction of the
sinus. Those growing in maxillary sinus may extend into
nose and cause nasal obstruction or swelling of the side
Radiographic
features:
of the nose.
Usually lobulated or rounded and has sharply defined
margin and the internal aspect is homogenous and
extremely radiopaque.

A lateral cephalometric skull projection shows a frontal

sinus osteoma as a well-defiend, uniformly radiopaque

Malignant neoplasms
of the paranasal
sinuses
Squamous cell
carcinoma
Pseudotumor

Squamous cell carcinoma

Definition: Squamous cell carcinoma from metaplastic
epithelium of the sinus mucosal lining.
Clinical features:

Radiographic features:

Facial pain or swelling, nasal Most carcinomas occur in

obstruction and lesion in the the maxillary sinuses but
oral cavity. The mean age of involvement of the frontal
the patient is 60 years
and sphenoid sinuses is
(range 25 to 89 years) and
also common and the
also lymph nodes are
internal aspect of the
involved in about 10% of
maxillary sinus has
cases. the symptoms are
radiopaque appearance.
present for about 5 months

Pseudotumor
Definition: Pseudotumor is descriptive name for a group
of related diseases of fungal origin that occur in the
paranasal sinuses.
Clinical features:

Radiographic features:

The symptoms may not be The radiographic findings in

very specific and may be
pseduotumor include
cause erosion of the walls
masses that cause erosion
of the involved sinus.
of bony walls of the involved
Altered nerve function
sinuses.
resulting from involvement
of the nerve or occlusion of
blood vessels by the mass

71-year-old man with inflammatory pseudotumor and malignant transformation of left

maxillary sinus. Patient had left gingival pain for 6 months. Axial (A) and coronal (B) CT
scans show soft-tissue lesion (M in B) in left maxillary sinus. Associated massive bony
destructions are evident. Radiologic primary diagnosis was malignant lesion with bony
destruction. Wide excision was performed. Pathologic results indicated inflammatory
pseudotumor with malignant transformation.

Extrinsic
inflammatory
diseases

Inflammatory
odontogenic disease
Clinical features:
Diffusion of inflammatory
exudate
Usually resolves in days
or weeks

Radiographic
features:
Homogeneous
radiopaque
Follows the contour of
the floor

Periostitis
Exudate from dental inflammatory lesions.
Can strip and elevate the periosteal lining of the cortical
bone of the floor of the maxillary antrum.

Radiographic Features
Thin radiopaque line, or it may be very thick or, rarely,
laminated
(similar to onion skin).

The halo-like appearnace of bone (arrow) surrounding

the palatal root of the first molar is the result of
periosteal new bone formation

Odontogenic
cysts
Most common group of extrinsic lesions that
encroach on the maxillary sinuses

1.Radicular cysts
2.Dentigerous cysts
3.Odontogenic keratocyst

Internal structure:

Homogeneous and
radiopaque.

Radiographic features:
Curved or oval shape
defined by a corticated
border.
The cyst may displace
the floor of the maxillary
antrum. In some cases
the cyst may enlarge to
the point that it has
encroached on almost the
entire sinus

Dentigerous cyst

Most common perioral radiolucency

Associated with the crown of an unerupted tooth
(in this instance, the upper right 8).
Has a well defined, corticated margin (arrows).

Radicular cyst

Periapical lucency, corticated margin, > 1.5cm

Arise from epithelial rests in the perodontal
ligament as a consequence of inflammation.

Odontogenic keratocyst containing a third molar tooth

inthe maxillary antrum.

Trauma

DENTAL STRUCTURES DISPLACED INTO

THE SINUS

Definition
Tooth roots may be fractured as a result of various
forms
of trauma, including iatrogenic causes.
Fractured roots may be forced into the sinus during
extraction

Clinical Features
No specific features may be visible if the root was
displaced into the sinus recently: However, the
dentist may note the absence of the root fragment
on examining the extracted tooth and be unable to
locate it anywhere .
Asking the patient to hold his or her nose while
attempting to breathe out through it will cause
bubbles to appear within the blood contained
within the fresh extraction socket.
The dental fragment usually has no effect on
surrounding structures; however, sinusitis may
result.

Radiographic Features
Location of the Roots or teeth in the sinus are
associated with premolars and molars because
the sinus is often in close proximity to the roots.
More often they are located near floor of the sinus
because of gravity .
Sometimes the displaced structure may be
submucosal, between the osseous wall of the
sinus and the periosteum.

Retained root into antrum

Coronal view shows the palatal root lodged into the

ostium of the maxillary sinus.

FIBROUS DYSPLASIA
May arise in
Maxillary bone
Sphenoid
bone
Frontal bone
Ethmoid bone
Temporal bone

Clinical Features

Facial asymmetry.
Nasal obstruction.
Proptosis.
Pituitary gland compression.
Impingement on cranial nerves.
Sinus obliteration.
Lesion may displace the roots of
teeth and cause teeth to separate
or migrate.
More common in children and
young adults

Radiographic Features
The posterior maxilla is the most common location.
Usually not well defined, tending to blend into the
surrounding bone.
The normal radiolucent maxillary antrum may be
partially or totally replaced by the increased
radiopacity of this lesion .
The degree of radiopacity depends on its stage of
development and the relative amounts of bone present.
The radiopaque areas have the characteristic "ground
glass"
appearance on extraoral radiographs or an "orange peel"
appearance on intraoral views.

Fibrous
dysplasia

Monostotic form more common in the craniofacial region

Ground glass change with areas of sclerosis (arrows)
More ill-defined border compared to ossifying fibroma

Thank you