Maxillary Sinus Disease -Power Point Presentation

7/29/2019 Maxillary Sinus Disease -Power Point Presentation

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Good

Morning



Imaging of salivary gland

Salivary gland

Parotid

Submandibular

Radiographic projections used

OPG Oblique lateral

Rotated PA or AP Intraoral view of the cheek

OPG Oblique lateral Lower 90° occlusal (to show the duct) Lower oblique occlusal (to show the

gland) True lateral skull with the tongue

depressed



Imaging techniques

Plain films

Contrast radiography- sialography

Ultrasound CT scan

Scintigraphy

Flow rate studies Magnetic resonance imaging (MRI).



Plain films

Occlusal radiographs- anterior 2/3rd duct

OPG- overlapping

Lateral oblique- 150

view , post 1/3rd

duct Intra buccal

Postero anterior view

Lateral ceph



Ultrasonography

CT scan



Sialography is a radiographic procedure that isuseful diagnostic aid in the detection of masses

and pathological processes in the salivary glandsby injection of radio-opaque die through majorsalivary gland ductal system.



Detection of a calculus / calculi / foreign body

Determination of the extent of destruction of gland secondary

to obstructing calculi / foreign body

Detection of fistulae , diverticuli or strictures

Detection / diagnosis of recurrent swelling and inflammatory

processes

Tumor – location / size

Selection of a site for biopsy

Outline the plane of facial nerve

Residual stone / tumor, fistula or stenosis



Known sensitivity to Iodine compounds

Acute inflammation of salivary system

Interfere with thyroid function tests



DEFINITION: Radiopaque substances that have beendeveloped to alter artificially the density of different partsof the patient

IDEAL REQUISITES:

Physiologic properties similar to saliva

Miscibility with saliva

Absence of systemic / local toxicity

Low surface tension and low viscosity

Easy elimination

Absorption and detoxification



Iodine-based aqueous solutions:

— Ionic monomers :

* iothalmate (e.g. Conray®)

* metrizoate (e.g. Isopaque®)

• diatrizoate (e.g. Urografin®)

— Ionic dimers :

• ioxaglate (e.g. Hexabrix®)

— Non-ionic monomers :

* iopamidol (e.g. Niopam®)

* iohexol (e.g. Omnipaque®)

* iopromide (e.g. Ultravist®)



-Iodine-based oil solutions such asLipiodol® (iodized poppy seed oil) used for

lymphography and sialography

-Water insoluble organic iodine compounds

eg Pentopaque



Contrast medium Oil-based

Aqueous

Advantages Densely radiopaque, thus

show good contrast High viscosity, thus slow

excretion from the gland

Low viscosity, thus easilyintroduced

Easily and rapidly

removed from the gland Easily absorbed and

excreted if extravasated

DisadvantagesExtravasated contrast mayremain in the soft tissues formany months, and may

produce a foreign bodyreactionHigh viscosity meansConsiderable pressureneeded to introduce thecontrast, calculi may

be forced down themain duct

Less radiopaque, thus showreduced contrastExcretion from the gland isvery rapid unless used in aclosed system



EQUIPMENTS

•Polyethylene tubing with blunt end metallic tip

•5 to 10cc syringe

•Lacrimal dilators

•

Contrast medium

•Lemon extract /Lemon slices



PROCEDURE

3 Phases 1) Preliminary plain film

evaluation

2) Injection / Filling phase

3) Parenchymal / Evacuation

phase



•Location of orifice of the duct

•

Duct exploration with Lacrimal probe•Insertion of sialographic canula into the duct

•Injection(slow) of contrast medium into the

duct•3 to 4 sets of radiographs are taken during

procedure

-Preliminary plain films-Filling phase films

-Post evacuation phase films

•

Instruction to the patient

PROCEDURE



3 methods of injecting dye

Simple injection technique Oil-based or aqueous contrast medium is introduced using gentle

hand pressure until the patient experiences tightness or discomfortin the gland, (about 0.7 ml for the parotid gland, 0.5 ml for thesubmandibular gland).

Advantages Simple Inexpensive.

Disadvantages The arbitrary pressure which is applied may cause damage to the

gland Reliance on patient's responses may lead to underfilling or

overfilling of the gland.



Hydrostatic technique Aqueous contrast media is allowed to flow freely into the gland

under the force of gravity until the patient experiences discomfort.

Advantages The controlled introduction of contrast medium is less likely to cause

damage or give an artefactual picture

Simple Inexpensive.

Disadvantages Reliant on the patient's responses Patients have to lie down during the procedure, so they need to be

positioned in advance for the filling-phase radiographs.



Continuous infusion pressure-monitored technique

Using aqueous contrast medium, a constant flow rate isadopted and the ductal pressure monitored throughoutthe procedure.

Advantages The controlled introduction of contrast media at known

pressures is not likely to cause damage Does not cause overfilling of the gland Does not rely on the patient's responses.

Disadvantages Complex equipment is required

Time consuming.



COMPLICATIONS

•Over Distension

•Foreign body Reaction

•

Chronic Inflammatory Process



Parotid gland

• The duct structure within the gland branchesregularly and tapers gradually towards the peripheryof the gland, the so-called tree in winter appearance

Submandibular gland

• This gland is smaller than the parotid, but the overall appearance is similar — the so-called bush in winter appearance



Ductal changes associated with: — Calculi — Sialodochitis (ductal inflammation/infection)

• Glandular changes associated with: — Sialadenitis (glandular inflammation/infection) — Sjogren's syndrome

— Intrinsic tumours.



Calculus:

Filling defects in main duct distal tocalculus, lobules are overfilled.

Ductal dilatation caused by associated

Sialodochitis Emptying film shows retained contrast

media



Sialodochitis:

Segmental strictures & dilation of larger ducts.“sausage – string ” appearance

Acini & ductules are not dilated



Glandular changes:

Sialadenitis:- Dots or blobs of contrast mediumwithin the gland, an appearance

known as sialectasis caused by theinflammation of the glandulartissue producing saccular dilatationof the acini- Main duct & inter lobular ductsappear normal in caliber.



Sjogren`s syndrome:

Wide spread dots / blobs of contrast media within the

gland. “ Snow – storm ” appearance, Punctate Sialectasis.

Due to the wearing of epithelial lining the intercalated

ducts allow escape of contrast media.



Intrinsic tumors: • An area of underfilling within the gland, due to ductalcompression by the tumour

• Ductal displacement — the ducts adjacent to the tumour areusually stretched around it, known as BALL IN HAND APPEARANCE.• Retention of contrast medium in the displaced ducts during the

emptying phase.

PARA NASAL SINUS



PARA NASAL SINUS

AND IMAGING



Normal appearance

Radiolucent cavity in the maxillaWell-defined, dense, corticatedradiopaque marginsInternal bony septa and blood vesselcanals in the walls all produce their

own shadows.Thin lining epithelium is not normallyseen.



Investigation

Periapical (paralleling or bisectedangle technique)

Dental panoramic

0° occipitomental (0° OM)

Upper oblique occlusal

Area of antrum shown

Floor Base of antral cavity Relationship with upper posterior teeth

Floor Posterior wall Base of antral cavity Relationship with upper posterior teeth Medial wall Allows comparison of both sides

Main antral cavity Lateral wall Roof or upper border

Medial wall Allows comparison of both sides

Floor Lower half of antral cavity Relationship with upper posterior teeth



True lateral skull

Linear or spiral tomography incoronal or sagittal plane

Computed tomography (CT) orMRI

Main antral cavity Posterior wall Anterior wall

Note: Superimposition of oneantral shadow on the other

Main antral cavity Floor Anterior wall Lateral wall Posterior wall Medial wall Roof or upper border Allows comparison of both sides

(coronal only)

Main antral cavity Floor All walls Roof or upper border Surrounding structures

Allows comparison of both sides Images hard and soft tissue



Radiological signs for antral disease

Opacity within the antrum — total or partial

- the shape, site and extent of the opacity often

determining the differential diagnosis, e.g. afluid level

Alteration in the integrity of the antral walls,including discontinuity owing to a fracture or

destruction by an intrinsic or extrinsic tumour Alteration in the antral outline, including

expansion or compression owing to an intrinsicor extrinsic lesion

Presence of a foreign body within the antrum.



Common pathologies affecting antra

• Infection/inflammation — Acute / Chronic sinusitis

• Trauma

— Oro-antral communication

— Fractures — Foreign bodies

• Cysts

— Intrinsic — Extrinsic

• Tumors — Intrinsic — Extrinsic

• Other bone abnormalities

— Fibrous dysplasia

— Paget's disease — Osteo etrosis.



ACUTE SINUSITIS

Causes • Upper respiratory tract infection, particularly the commoncoldTrauma, including roots or teeth displaced into the antrum orthe formation of an oroantral communication

• Apical infection associated with the upper posterior teeth

CHRONIC SINUSITIS

Causes • Prolonged antral infection • Continued presence of a foreign body or oroantralcommunication.

Radiographic features of acute sinusitis



Radiographic features of acute sinusitis

Total opacity within the antral cavity

Opaque zone confined to base of antrum, with initialcollection of fluid, before the combination of mucosalthickening and fluid totally opacifies the antrum

Features of apical inflammatory changes, if infectedteeth are involved — resorption and remodellingof the antral floor producing

antral halo

Evidence of a foreign body



Chronic sinusitis

Mucoperiosteal thickening of the maxillary sinus

Localized at the base of the sinus.

Generalized around the entire wall of the sinus.

Complete filling of the sinus except about theostium on the medial wall.

Complete filling of the sinus.



Causes of Oroantral communication

Extraction of closely related upperposterior teeth can remove part of theantral floor or fracture the tuberosity

Inappropriate or incorrect use of elevatorsduring root or tooth removal — may alsocause the root, or rarely the tooth, to be

displaced into the antrum.



Radiographic features

Break in the continuity of the floor may be evident

Characteristic features of acute or chronic sinusitis owingto the ingress of bacteria

Evidence of the displaced root or tooth — a second viewof the antrum with the head in a different position may berequired to ascertain the exact location of the displacedobject



MUCOCELES AND MUCOUS RETENTION CYSTS

Pathogenesis is obstruction due to inflammation or

allergy.

Main radiographic features

Incidental finding

Well-defined, round, dome-shaped opacity within the antrum Usually no evidence of thickening of the remainder of the

epithelial lining

Usually no alteration of the antral outline

Occasionally bilateral



Foreign bodies

Causes

Displaced root fragments or teeth

Excess root canal filling material forced through the apexof an upper posterior tooth during endodontics

Antrolith — calcification within the antrum Foreign material pushed into the antrum through an

existing oro-antral communication.

Main radiographic features The presence, position and often the nature of the

foreign body

Occasionally associated sinusitis.



POLYPS

Thickened mucous membrane of achronically inflamed sinus frequently formsinto irregular folds called polyps.



Malignant neoplasm affecting antra

Air sinus Investigation



Air sinus Frontal

Sphenoidal

Ethmoidal

Investigation 0° occipitomental (0° OM) PA skull True lateral skull

Tomography CT/ MRI

0° occipitomental (with the patient's mouthopen)

True lateral skull Submento-vertex (SMV) Tomography CT/ MRI

0° occipitomental

30° occipitomental True lateral skull PA skull Tomography CT /MRI



Thank You

Maxillary Sinus Disease -Power Point Presentation

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