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‫بسم هللا الرحمن الرحيم‬
The National Ribat University
Faculty of Graduate Studies and
Scientific Research
Anatomical Variations and Abnormalities of Maxillary Sinuses on
Computed Tomography in Sudanese People
A thesis Submitted in Partial Fulfillment Required For
M.Sc. in Human and Clinical Anatomy
By:
Salma Ali Akasha
Supervisor:
Dr .Yasir Seddeg Abdel Ghany
2014
1
‫بسم هللا الرحمن الرحيم‬
‫قال تعالى‪:‬‬
‫ف تح ِيي ال َمو َتى َقا َل أَ َولَم تؤمِن َقا َل َبلَى‬
‫( َوإِذ َقا َل إِب َراهِيم َرب أَ ِرنِي َكي َ‬
‫ك ثم اج َعل َعلَى‬
‫َولَكِن لِ َيط َمئِن َقل ِبي َقا َل َفخذ أَر َب َعة م َِن الطي ِر َفصرهن إِلَي َ‬
‫ّللا َع ِزيز َحكِيم )‬
‫كل َج َبل مِنهن جزءا ثم ادعهن َيأتِي َن َك َسعيا َواعلَم أَن َ‬
‫صدق هللا العظيم‬
‫سورة البقرة ا ألية)‪(260‬‬
‫‪2‬‬
Dedication
To my parents,
Husband,
Brothers,
Sisters,
Family,
Relatives,
Colleagues and
Teachers
I
Acknowledgement
I would like to express my grateful appreciations to Dr. Yasser Seddeg, my
supervisor, for helpful comments, useful remarks and encouragement that I
have received from him throughout the study.
My grateful appreciations are extended to Professor Tahir Osman, for his
guidance during the study period.
I would like to thank Dr. Kamal Badawi for the support on the way.
Also I am owing a favor to my friend and colleague Hagir ALTahir and her
cousin Rihab Abdel Raheem M. Ali, for assistance obtaining the CT image
database.
I would also like to thank all of my friends and colleagues in department of
Anatomy, National Ribat University especially Dr.Hayder, Khalid Taha, Hadba
Gazi, Wala Alsayh, Sara and Nusayba Abdoalrahman, who supported me.
I am sincerely indebted to my miraculous family especially my husband and my
sister Mona for their unconditional support throughout the period of my study.
II
Table of Contents
Title
page
Dedication
I
Acknowledgment
II
Table of Contents
III
List of tables
List of figures
VI
VII
Abbreviations
VIII
Abstract
IX
Abstract (Arabic)
CHAPTER ONE
Introduction and Objectives
X
Introduction and Objectives
1
1.1.
Introduction
1
1.2.
Objectives
7
1.2.1.
General objective
7
1.2.2.
Specific objectives
7
1.
CHAPTER TWO
Literature Review
2.
Literature review
8
2.1.
Anatomy of paranasal air sinuses
8
2.2.
The maxillary sinus anatomy
9
2.2.3.
Ostiomeatal complex
10
2.2.4.
Development:
11
2.2.5.
Histology of the maxillary sinus:
12
III
2.2.5.1.
The epithelial layer:
12
13
2.2.6.
2.2.7.
2.2.8.
The subepithelial connective tissue layer
(lamina propria)
Vascular supply of the maxillary sinus:
Lymph drainage of the maxillary sinus:
Nerve supply of the maxillary sinus:
2.2.9.
Function of the maxillary sinus:
15
2.2.10.
Anatomical variations of maxillary sinus:
15
2.2.10.1.
Maxillary sinus pneumatization
15
2.2.10.2.
Maxillary sinus hypoplasia (MSH):
16
2.2.10.3.
Maxillary sinus septa (antral septa)
16
2.2.10.4.
Accessory maxillary ostia
16
Abnormalities of maxillary sinus
16
2.2.11.1.
Maxillary Sinusitis:
16
2.2.11.2.
Mucous Retention Cyst
17
2.2.11.3.
Foreign Objects in Sinus:
17
2.2.11.4.
Oro-antral Fistula
18
Increased Mucosal thickness (Mucosal thickening):
18
2.2.11.6.
Genetic, Metabolic & Tumor-like disease
18
2.2.11.7
Clinical considerations about the maxillary sinus
19
Previous studies:
20
CHAPTER THREE
Material and Methods
Material and Methods
22
Study design
22
2.2.5.2.
2.2.11
2.2.11.5.
2.2.12.
3.
3.1.
IV
13
14
14
3.2.
Study area
22
3.3.
Study duration
22
3.4.
Inclusion criteria
22
3.5.
Exclusion criteria:
22
3.6.
Sampling
22
3.7.
Methods of the study
23
3.8.
Data collection
22
3.9.
Data analysis
22
3.10.
Ethical considerations:-
23
CHAPTER FOUR
Results
4.
24
Results
CHAPTER FIVE
Discussion
5.
Discussion
37
CHAPTER SIX
Conclusions & Recommendations
6.
Conclusions & Recommendations
38
38
6.1.
Conclusions
6.2
Recommendations
38
CHAPTER SEVEN
7.
References
7.1.
References
7.2.
Appendix
39
42
V
List of Tables
Tables
Title
Page NO
distribution of sinusitis patients and normalpersons
26
Table 4.2
Distribution of age among study population
27
Table 4.3
Original home distribution among study population
28
Table 4.4
distribution of gender among study group
29
Table 4.5
Maxillary.Rt sinus distribution
30
Table 4.6
Maxillary Lt sinus distribution
31
Table 4.7
Distribution of symmetry of the maxillary sinuses
32
Distribution of values of maxillary Rt sinus variations
33
Table 4.1
Table 4.8
Table 4.9
at different age groups
Distribution of values of maxillary Lt sinus variations
33
at different age groups
Table 4.10
Maxillary Rt sinus variations in relation to sinusitis
34
Table 4.11
Symmetry of the Rt maxillary sinus in relation to
34
sinusitis
Table 4.12
maxillary Rt sinus variation in relation to gender
35
Table 4.13
Table maxillary Lt sinus variation in relation to gender
35
Variations of the maxillary sinus in different studies
37
Table 5.1
VI
List of Figures
Figures
Fig 4.1
Fig 4.2
Fig 4.3
Title
Page
Fig 4.1; distribution of sinusitis patients and
normal persons
Distribution of age among study population
26
Original home distributions among study
28
27
population
Fig 4.4
distribution of gender among study group:
29
Fig 4.5
Maxillary. Rt sinus distribution
30
Fig 4.6
Maxillary Lt sinus distribution
31
Distribution of symmetry of the maxillary
32
Fig 4.7
sinuses
VII
Abbreviations
CT: Computed Tomography
OMU:Osteomeatal Unit
MSH: Maxillary Sinus Hypoplasia
Rt: Right
Lt: Left
O. Home: Original Home
VIII
Abstract
 Background: the maxillary sinus variations are common among
populations. These variations may associate with inflammatory diseases
like sinusitis or other diseases (allergic rhino-sinusitis and bronchial
asthma).
 Aim: The aim of this study was to investigate maxillary sinus variations
by using CBCTin adult Sudanese population.
 Methods: 30 (Males=7, Females=23) cases of age group 13-69 years are
subjected to 3D axial multislider CT scan.
 Results: Variations were diagnosed in 30 of samples. There was no
significant difference between genders and age groups. Mucosal
thickening was the most prevalent abnormality (66.7%), followed by
antral septa (23.3%), obliterated sinus (16.6%) and mucosal polyp
(3.3%). No association was observed between the maxillary sinus
variations and the presence of sinusitis.
 Conclusion: variations in maxillary sinus emphasize how important it is
for the dentomaxillofacial radiologist, otolaryngologists, radiologist and
anatomist to be aware about the anatomical variations of the maxillary
sinuses.
IX
‫ملخص الدراسة‬
‫الخلفية‪ :‬اختالفات الجيوب األنفية الفكية شائعة بين السكان‪ .‬هذه االختالفات قد تكون ذات عالقة مع‬
‫األمراض االلتهابية مثل التهاب الجيوب األنفية أو أمراض أخرى مثل حساسية األنف و التهاب الجيوب‬
‫األنفية والربو القصبى‪.‬‬
‫باستخدام االشعة المقطعية الهدف‪ :‬كان الهدف من هذه الدراسة هو تشخيص اختالفات الجيوب األنفية‬
‫الفكية فى كبار السودانيين‪.‬‬
‫الطريقة‪ :‬تعرض ‪ 30‬شخص (الذكور = ‪ ،7‬اإلناث = ‪ )23‬من الفئة العمرية ‪ 69-13‬سنة إلى اشعة‬
‫مقطعية محورية‪.‬‬
‫النتائج‪ :‬تم تشخيص االختالفات في ‪ 30‬من العينات‪ .‬لم يكن هناك فرق كبير بين الجنسين و الفئات‬
‫العمرية وكانت سماكة الغشاء المخاطي األكثر انتشارا ( ‪ ،) ٪ 66.7‬تليها الحاجزالجيبى غاري ( ‪)٪23.3‬‬
‫‪ ،‬الجيوب األنفية طمس ( ‪ ،) ٪ 16.6‬و ورم الغشاء المخاطي ( ‪ . ) ٪3.3‬وقد لوحظ عدم وجود عالقة‬
‫بين التغيرات فى الجيب الفكي وو جود التهاب الجيوب األنفية‪.‬‬
‫الخاتمة ‪ :‬االختالفات في الجيب الفكي تككد كم هو مهم الختصاىى االنف واالذن والحنجر‬
‫واختصاىى التشريح ليكونوا على‬
‫األشعة‪،‬اختصاىى جراحة الوجه والفكين واالسنان‬
‫‪،‬اختصاىى‬
‫َ‬
‫َ‬
‫َ‬
‫بينة حول االختالفات التشريحية للجيوب الفكية‪.‬‬
‫‪X‬‬
Chapter One
Introduction
and Objectives
I
1. Introduction and objectives
1.1 Introduction
Five skull bones the frontal, sphenoid, ethmoid, and paired maxillary
bones contain mucosa-lined, air-filled sinuses that give them a rather motheaten appearance in an X-ray image. These particular sinuses are called
paranasal sinuses because they cluster around the nasal cavity.
Small openings connect the sinuses to the nasal cavity and act as “two-way
streets”; air enters the sinuses from the nasal cavity, and mucus formed by the
sinus mucosae drains into the nasal cavity. The mucosae of the sinuses also help
to warm and humidify inspired air [1]
The osteomeatal unit (OMU) includes the (1) maxillary sinus ostium, (2)
ethmoid infundibulum, (3) anterior ethmoid air cells, and (4) frontal recess.
They are referred to as the anterior sinuses. The OMU is the key factor in the
pathogenesis of chronic sinusitis. The ethmoid sinus is the key sinus in the
drainage of the anterior sinuses. It is vulnerable to trauma during surgery due to
its close relationship with the orbit and the anterior [2].
The paranasal sinuses allow the skull to increase in size without a
Corresponding change in the mass (weight) of the bone. In addition, the
paranasal sinuses serve as resonating (echo) chambers within the skull that
intensify and prolong sounds, thereby enhancing the quality of the voice [3].
All the sinuses are lined with respiratory mucous membrane,
incorporating a sensory nerve supply; the region of the ostium is the most
sensitive part, with the main part of each sinus being relatively insensitive [4].
This mucous membrane consists of pseudostratified ciliated columnar
epithelium with goblet cells, which secrete a layer of mucus.
The glands produce a film of mucus which is moved by the cilia in spiral
fashion towards the ostium [4].
1
Most sinuses are rudimentary or absent at birth, but enlarge appreciably during
the eruption of the permanent teeth and after puberty, events that significantly
alter the size and shape of the face [5].
Infections from the nasal cavity may spread into the paranasal sinuses.
The openings of the sinuses into the nose are quite small, and any
swelling of the mucous membrane of the nose will obstruct their drainage. If
bacteria grow in the obstructed sinuses, pus is produced and the painful
condition of sinusitis results. The maxillary sinus is poorly equipped to drain
itself because the position of its opening at the biggest point in the sinus defies
gravity [6].
Paranasal sinus anatomy and variations have gained interest with the
introduction of functional endoscopic sinus surgery and the concept of the
ostiomeatal complex [7].
The maxillary sinus is the space within the body of the maxilla, known
in earlier days as the maxillary antrum (of Highmore). The sinus is pyramidal in
shape, the base at the lateral wall of the nose and the apex in the zygomatic
process of the maxilla.
The roof of the sinus is the floor of the orbit. The floor of the sinus is the
alveolar part (tooth-bearing area) of the maxilla; it lies at a lower level than the
floor of the nose. Anterior and posterior walls are the corresponding walls of the
maxilla. Certain ridges appear within the cavity; a constant one is at the junction
of roof and anterior wall, produced by the downward passage of the infraorbital
nerve with in its canal.
The maxillary sinus is present at birth, but is no more than a shallow slit,
slightly overgrown into a short culde- sac anteriorly and posteriorly. It
excavates the lateral wall of the nose, beneath the middle concha, and lies just
beneath the medial side of the floor of the orbit.
The body of the neonatal maxilla lateral to this is full of developing teeth.
2
The sinus varies in size; a large one may extend into the zygomatic process of
the maxilla and into the alveolar process so that the roots of the three molar
teeth (and possibly of the premolars also) lie immediately beneath the floor or
project into it.
The roots are usually enclosed in a thin layer of compact bone; when
this is absent the apex of the root is in contact with the mucous membrane.
Extraction of such a tooth must leave a fistula by rupture of the mucous
membrane.
These fistulae mostly heal spontaneously.
The ostium of the sinus is high up and well back on its nasal wall. It is
2-4 mm in diameter. (A second smaller ostium often lies posteriorly.) It opens at
the posterior end of the semilunar hiatus in the middle meatus of the lateral wall
of the nose.
Blood supply by small arteries that pierce the bone, mostly from the
facial, maxillary, infraorbital and greater palatine arteries, and veins accompany
these
vessels to the facial vein and to the pterygoid plexus.
Lymph drainage For the most part via the infra orbital foramen or the ostium;
in either case the lymphatics flow to the submandibular nodes.
Nerve supply by various branches of the maxillary nerve: superior alveolar
(posterior, middle and anterior), the greater palatine and infraorbital.
The dental branches of the posterior superior alveolar nerve pass
forwards in the bone above the apices of the molar teeth, which they supply.
Minute branches pierce the bone to supply the mucous membrane of the sinus.
The middle superior alveolar nerve leaves the infraorbital nerve on the
floor of the orbit and runs down in the lateral wall of the maxilla to supply the
premolar
teeth, and the overlying mucous membrane of the sinus. It forms loops in the
bone with the posterior and anterior superior alveolar nerves (superior dental
3
plexus). It is sometimes absent, in which case its supply to the teeth is usually
taken over by the anterior superior alveolar nerve.
The anterior superior alveolar nerve leaves the infra orbital nerve in the
infraorbital canal in the roof of the sinus. It passes laterally, and then curves
medially below the infraorbital foramen, in the anterior wall of the maxilla. It
supplies the pulps of the canine and incisor teeth, and the anteroinferior
quadrant of the lateral wall of the nose, spilling over on to the floor of the nose
and perhaps the septum anteriorly. Branches innervate the mucous membrane of
the anterior wall of the sinus.
The greater palatine nerve in its canal gives off minute branches which
perforate the maxilla to supply the posterior part of the medial wall of the sinus.
The infraorbital nerve gives perforating branches that supply the roof of the
sinus (4).
A precise knowledge of the anatomy of the paranasal sinuses is essential
for the clinician. Conventional radiology does not permit a detailed study of the
nasal cavity and paranasal sinuses, and has now largely been replaced by
computerised tomographic (CT) imaging. This gives an applied anatomical
view of the region and the anatomical variants that are very often found. The
detection of these variants to prevent potential hazards is essential for the use of
current of endoscopic surgery on the sinuses [8].
.
Computed tomography (CT) images allow the location of anatomic
structures and provide information about bone dimensions and morphology,
data of great importance for dental implant planning [9].
Variations of the nasal cavity and paranasal sinuses are very important
for the otolaryngologist in functional endoscopic sinus surgery.
The success of functional endoscopic surgery depends on adequate
knowledge of the complicated anatomy of the paranasal sinuses, which is
variable. It is important to recognize the clinical and surgical significance of
these variations.
4
Certain anatomic variations are thought to be predisposing factors for the
development of sinus diseases and thus it becomes necessary for the radiologist
to be aware of these variations, especially if the patient is a candidate for
functional endoscopic sinus surgery (FESS) [2].
Anatomy of maxillary sinus is variable. Precise understanding of these
variables will help a surgeon to avoid unnecessary complications during
maxillary sinus surgery.
So one of these variations is maxillary sinuses septa and they are thin
walls of cortical bone present within the maxillary sinus, with variable number,
thickness and length. Such septa may divide the sinus into two or more cavities
arising from the inferior and lateral walls of the sinus. Septa originating from
teeth may be classified according to their development at the different phases of
the dental eruption.
Another variation is accessory maxillary ostia they are generally solitary, but
occasionally may be multiple. Such variation may be congenital or secondary to
sinusal diseases.
Also there is avariation which is hypoplasia of one maxillary antrum
which is present in up to 0.3% of the population.
Also mucosal elevation as the adult sinus varies in size; a large one may
extend into the zygomatic process of the maxilla and into the alveolar process
so that the roots of the three molar teeth (and possibly of the premolars also) lie
immediately beneath the floor or project into it. The roots are usually enclosed
in a thin layer of compact bone; when this is absent the apex of the root is in
contact with the mucous membrane.
Researches about the maxillary sinus variations were done worldwide,
but there is no study done here in Sudan.
5
So this study aimed to find out the anatomical variations of the
maxillary sinus among Sudanese people. Also to find out the relation between
the anatomical variations of the maxillary sinus and the gender, age, residency,
occupation.
6
Chapter Two
Literature Review
1
1.2. Objectives
1.2.1 General Objective:
This study aimed to find out the anatomical variations of the
maxillary sinus among Sudanese people.
1.2.2 Specific Objective
1. To show any gender variations of maxillary sinus.
2. To find out any correlation between the sinus variations and age.
3. To find out any relation between the sinus variations and residency.
4. To find out any correlation between the sinus variations and
occupation.
5. To compare the results of this study with data from other studies done
worldwide.
7
2. Literature review
2.1Anatomy of paranasal air sinuses
The paranasal sinuses are the frontal, ethmoidal, sphenoidal and
maxillary sinuses, housed within the bones of the same name.
They all open into the lateral wall of the nasal cavity by small apertures that
permit both the equilibration of air between the various air spaces and the
clearance of mucus from the sinuses into the nose via a mucociliary escalator.
The detailed position of these apertures, and the precise form and size of each of
the sinuses, varies enormously between individuals.
Respiratory epithelium extends through the apertures of the paranasal
sinuses to line their cavities, a feature that unfortunately favours the spread of
infections. Sinus mucosa is thinner, less vascular and has fewer goblet cells than
nasal mucosa. Cilia are always present in the mucosa near the apertures but less
evenly distributed elsewhere within the sinuses.
Most sinuses are rudimentary or absent at birth, but enlarge appreciably
during the eruption of the permanent teeth and after puberty, events that
significantly alter the size and shape of the face.
The functions of the paranasal sinuses remain speculative. They clearly
add some resonance to the voice, and also allow the enlargement of local areas
of the skull while minimizing a corresponding increase in bony mass. It is likely
that such growth-related changes serve to strengthen particular regions, e.g. the
alveolar process of the maxilla when the secondary dentition erupts, but they
may also function in contouring the head to provide visual signals indicating the
individual's status in a social context (e.g. gender, sexual maturity and group
identity).
8
2.2.1. The maxillary sinus anatomy
The maxillary sinus (maxillary antrum), is the largest of the paranasal
sinuses. It fills the body of the maxilla and is pyramidal in shape. The base is
medial and forms much of the lateral wall of the nasal cavity.
The floor, which often lies below the nasal floor, is formed by the
alveolar process and part of the palatine process of the maxilla. It is related to
the roots of the teeth, especially the second premolar and first molar, but may
extend posteriorly to the third molar tooth and/or anteriorly to incorporate the
first premolar, and sometimes the canine. Defects in the bone overlying the
roots are not uncommon.
The roof of the sinus forms the major part of the floor of the orbit. It
contains the infraorbital canal which may exhibit dehiscences.
The lateral truncated apex of the pyramid extends into the zygomatic
process of the maxilla, and may reach the zygomatic bone, in which case it
forms the zygomatic recess which throws a V-shaped shadow over the antrum
on a lateral radiograph.
The facial surface of the maxilla forms its anterior wall, and is
grooved internally by a delicate canal (canalis sinuosus) which houses the
anterior superior alveolar nerve and vessels as they pass forwards from the
infraorbital canal.
The posterior wall is formed by the infratemporal surface of the
maxilla: it contains alveolar canals that may produce ridges in the sinus and that
also conduct the posterior superior alveolar vessels and nerves to the molar
teeth.
The medial wall is deficient posterosuperiorly at the maxillary hiatus, a large
opening which is partially closed in an articulated skull by portions of the
perpendicular plate of the palatine bone, the uncinate process of the ethmoid
9
bone, the inferior nasal concha, the lacrimal bone, and the overlying nasal
mucosa, to form an ostium and anterior and posterior fontanelles.
The ostium usually opens into the inferior part of the ethmoidal
infundibulum, and thence into the middle meatus, via the hiatus semilunaris (the
hiatus forms the area above the superior edge of the uncinate process).
The fontanelles are covered only by periosteum and mucosa and may
contain accessory Ostia which may be visible on CT. All of the openings are
nearer the roof than the floor of the sinus which means that the natural drainage
of the maxillary sinus is reliant on an intact mucociliary escalator the cilia of the
sinus mucoperiosteum normally beat towards the ostium.
The maxillary sinus may be incompletely divided by septa; complete
septa are very rare. The thinness of its walls is clinically significant in
determining the spread of tumours from the maxillary sinus.
A tumour may push up the orbital floor and displace the eyeball; project into the
nasal cavity, causing nasal obstruction and bleeding; protrude onto the cheek,
causing swelling and numbness if the infraorbital nerve is damaged; spread
back into the infratemporal fossa, causing restriction of mouth opening due to
pterygoid muscle damage and pain; or spread down into the mouth, loosening
teeth and causing malocclusion.
Extraction of molar teeth may damage the floor, and impact may
fracture its walls. Hypoplasia of one maxillary antrum is present in up to 0.3%
of the population.
2.2.3. Ostiomeatal complex
The term ostiomeatal complex, or ostiomeatal unit, refers to the area
that includes the maxillary sinus ostium, ethmoid infundibulum and the hiatus
semilunaris. It is the common pathway for drainage of secretions from the
maxillary and anterior group of ethmoidal sinuses; where the uncinate process
attaches to the lateral nasal wall the complex also drains the frontal sinus. [5]
10
2.2.4. Development:
The maxillary sinuses are the only sizable sinuses present at birth. At
birth they have the size of a small lima bean measuring about 8X4 mm, and are
situated with their longer dimension directed anteriorly and posteriorly.
They develop at the third month of intrauterine life, in the place existing
between the oral cavity and the floor of the orbit.
They develop as evagination of the mucous membrane of the lateral
wall of the nasal cavity at the level of the middle nasal meatus forming a minute
space that expands primarily in an inferior direction into the primordium of the
maxilla.
The maxillary sinus enlarges variably and greatly by pneumatization
until it reaches the adult size by the eruption of the permanent teeth.
Enlargement of the maxillary sinus is consequent to facial growth.
Growth of the sinus slows down with decline of facial growth during puberty
but continues throughout life.
Growth of the maxillary sinus is determined by a process of bone
remodeling referred to as pneumitization which is carried out by resorption of
the internal walls (except the medial wall) at a rate that lightly exceeds growth
of the maxilla.
Fortunately the medial wall of the antrum is not resorptive (is
depository) while its nasal wall is resorptive, if both were resorpative, total
communication between the antrum and the nasal cavity may take place at one
time.
In young age, sinus growth by pneumotization is proportional to the
growth of the maxilla. However with the advance of age pneumatization
exceeds maxillary growth. Thus the antrum will expand at the expense of the
maxillary process.
11
Extension of the maxillary sinus in the processes of the maxilla leads to the
formation of antral or sinus recesses which include Zygomatic recess - Frontal
recess - Alveolar recess - Tuberosity recess.
Extension of the floor of the maxillary sinus in the alveolar process may
occur not only between the roots of adjacent teeth, but also between the roots of
individual teeth, leading too protrusion of the roots into the sinus cavity. At first
protruding roots are covered with paper thin bone but later on such bone will get
resorbed and
the roots protrude extensively into the sinus cavity through
openings, leaving the antral mucosa in direct contact with the periodontal
ligament of the projecting root apices.
In old age pneumatization becomes more pronounced, the floor of the sinus
moves at more downward position particularly when the maxillary teeth are
lost.
2.2.5 Histology of the maxillary sinus:
The maxillary sinus is lined with a mucous membrane of the respiratory type
however it is somewhat thinner than that lining the nasal cavity. The antral
mucous membrane is formed of an epithelial layer resting on a basement
membraneand a subepithelial connective tissue layer.
2.2.5.1 The epithelial layer:
The epithelial layer of the maxillary sinus lining is thinner than that of the
nasal cavity. Composed predominantly of pseudostratified columnar ciliated
cells derived from the olfactory epithelium of the middle nasal meatus, in
addition to columnar non ciliated cells, basal cells and mucous producing and
secreting goblet cells.
The pseudostratified columnar ciliated epithelial cells have nucleus and
electronlucent
cytoplasm
containing
numerous
mitochondria,
enzyme
containing organelles and basal bodies. The later serve to attach the ciliary
microtubules to the apical cell membrane.
12
Structurally the cilia are composed of 9 + 1 pairs of microtubules which
provide the mucociliary motile function to the sinus epithelium, which moves
the debris, microorganisms, and the mucous film lining the epithelial surface of
the sinus into the nasal cavity through the ostium maxillare. The cilia beat
automatically; they are not under nervous control.
The goblet cell is a unicellular gland; it is mucous synthetizing and secreating
cells. It resembles an inverted wine glass with a short stack like basal end
containing the nucleus and a swollen apical end containing mucin. It is an
apocrine gland, i.e. it pours its secretion through rupture of its apical cell
membrane that gets regenerated. So it has all the criteria of the synthesizing and
secreting cells.
2.2.5.2. The subepithelial connective tissue layer (lamina propria):
The lamina propria of the maxillary sinus lining is much thinner than that
of the nasal mucosa.
It is formed of connective tissue cells, and intercellular substance of
collagen bundles and few elastic fibers. It is moderately vascular. The lamina
propria contains subepithelial antral glands composed of mixed glands formed
of serous and mucous acini or seromucous acini as well as myoepithelial cells.
The antral glands are more concentrated in the lamina propria located around
the ostium maxillare. The mixed secretory products of the antral glands reach
the sinus cavity through their excretory ducts [10].
2.2.6. Vascular supply of the maxillary sinus:
The arterial supply of the maxilla is derived mainly from the maxillary
arteries via the superior anterior, middle and posterior alveolar branches and
from the infraorbital and greater palatine arteries. Branches of the posterior
superior alveolar artery and the infraorbital artery form an anastomosis in the
bony wall of the sinus, which also supplies the mucous membrane that lines the
nasal chambers. An extraosseous anastomosis frequently exists between the
13
posterior superior alveolar artery and the infraorbital artery. The intra- and
extra-osseous anastomoses form a double arterial arcade which supplies the
lateral antral wall and, partly, the alveolar process. Veins corresponding to the
arteries drain into the facial vein or pterygoid venous plexus on either side [5].
2.2.7 Lymph drainage of the maxillary sinus:
For the most part via the infra orbital foramen or the ostium; in either
case the lymphatics flow to the submandibular nodes.
2.2.8 Nerve supply of the maxillary sinus:
By various branches of the maxillary nerve one of them superior alveolar
(posterior, middle and anterior), the greater palatine and infraorbital. The dental
branches of the posterior superior alveolar nerve pass forwards in the bone
above the apices of the molar teeth, which they supply.
Minute branches pierce the bone to supply the mucous membrane of the
sinus. The middle superior alveolar nerve leaves the infraorbital nerve on the
floor of the orbit and runs down in the lateral wall of the maxilla to supply the
premolar teeth, and the overlying mucous membrane of the sinus. It forms loops
in the bone with the posterior and anterior superior alveolar nerves (superior
dental plexus). It is sometimes absent, in which case its supply to the teeth is
usually taken over by the anterior superior alveolar nerve.
The anterior superior alveolar nerve leaves the infra orbital nerve in the
infraorbital canal in the roof of the sinus. It passes laterally, and then curves
medially below the infraorbital foramen, in the anterior wall of the maxilla. It
supplies the pulps of the canine and incisor teeth, and the anteroinferior
quadrant of the lateral wall of the nose, spilling over on to the floor of the nose
and perhaps the septum anteriorly. Branches innervate the mucous membrane of
the anterior wall of the sinus.
The greater palatine nerve in its canal gives off
minute branches which perforate the maxilla to supply the posterior part of the
medial wall of the sinus.
14
The infraorbital nerve gives perforating branches that supply the roof of
the sinus.
So the maxillary sinuses are innervated by the infraorbital and anterior,
middle and posterior superior alveolar branches of the maxillary nerves (general
sensation), and nasal branches of the pterygopalatine ganglia (parasympathetic
secretomotor fibres) [4].
2.2.9 Function of the maxillary sinus:
1. Lightening the weight of the skull.
2. Resonance of voice.
3. Olfactory and respiratory modulations through regulation of the air
pressure within the sinus during respiration.
4. Inspired air conditioning.
5. Craniofacial protection against mechanical trauma.
6. Production of the bactericidal enzyme (lysozyme) which may be
significant in protection against bacterial infection of the nasal mucosa.
2.2.10 Anatomical variations of maxillary sinus:
The maxillary sinus can exhibit anatomic variations, such as
pneumatization, hypoplasia and antral septa. Moreover, maxillary sinus lesions
as mucosal thickening, sinusitis, mucous retention cyst, and antrochoanal polyp
are not uncommon.
2.2.10.1Maxillary sinus pneumatization:
It is an extension of maxillary sinus into a particular anatomic
structure such as alveolar ridge, anterior region, maxillary tuber, palate,
zygomatic bone, and/or orbitary region.
15
2.2.10.2Maxillary sinus hypoplasia (MSH):
Hypoplasia
of
one
maxillary
antrum
is
(MSH)
is
the
underdevelopment of the maxillary sinus.
The maxillary sinus can become hypoplastic during its embryological
development or late due to trauma, iatrogeny, or structural causes. The
narrow infundibular passage associated with the absence of a natural
ostium should cause mucosal thickening of the hypoplastic sinus.
Furthermore, MSH also causes the lateral extension of the lateral nasal
wall, making difficult the surgical procedures.
2.2.10.3 Maxillary sinus septa (antral septa):
They are thin walls of cortical bone present within the maxillary
sinus, with variable number, thickness and length. Such septa may divide
the sinus into two or more cavities arising from the inferior and lateral
walls of the sinus. Septa originating from teeth may be classified
according to their development at the different phases of the dental
eruption.
2.2.10.4 Accessory maxillary ostia:
They are generally solitary, but occasionally may be multiple. Such
variation may be congenital or secondary to sinusal diseases [9].
2.2.11. Abnormalities of maxillary sinus:
2.2.11.1 Maxillary Sinusitis:
Under normal circumstances, the maxillary sinus communicates with the
nasal cavity through the ostium. In sinusitis, the ostium may be blocked by a
swelling of the nasal mucosa, thus causing pain and difficulty in discharging
inflammatory fluid from the maxillary sinus. Maxillary sinusitis is a common
complication of a nasal cold. After a few days, there is a discharge of yellowish
mucopus or frank pus which may be blood stained. The patient may complain of
a sense of fullness over the cheek, especially on bending forward. Other
complaints in maxillary sinusitis may include headache, facial pain and
16
tenderness to pressure. The pain may also be referred to the premolar and molar
teeth which may be sensitive or painful to percussion. Maxillary sinusitis
(inflammation of maxillary sinus) may or may not be of dental source.
The dental source of maxillary sinusitis may be periapical infection, periodontal
disease, or perforation of the antral floor and antral mucosa at the time of dental
extraction. Roots and foreign objects forced into the maxillary sinus at the time
of operation may also be the causative factors of sinusitis. The non-dental
source of maxillary sinusitis may be allergic conditions, chemical irritation, or
facial trauma (fracture involving a wall or walls of the maxillary sinus). The
spectrum of radiographic appearances that may result from maxillary sinusitis
are opacification (cloudiness) of the sinus, mucosal thickening (hyperplastic
mucosa), and presence of a fluid level.
2.2.11.2 Mucous Retention Cyst:
The mucous retention cyst of the antrum represents an inflammatory
lesion with mucous extravasation into the submucosa of the antrum (mucosal
thickening). It emanates from the antral floor as a smooth-surfaced domeshaped elevation (mucosal polyp).
2.2.11.3 Foreign Objects in Sinus:
A root of a tooth that remains after extraction may be accidentally
pushed into the maxillary sinus by a clinician. The root tip acts as a nidus for
calcific deposits and may form a calcified mass or stone (antrolith). A root tip in
the sinus cavity does not have a surrounding lamina dura and it may change its
position in the sinus with changes in head tilt. If a root tip is situated between
the antral mucosa and the floor of the maxillary sinus, it does not change its
position with changes in head tilt. This location of the root below the antral
mucosa is not conducive for calcific deposits.
17
2.2.11.4 Oro-antral Fistula:
An oro-antral fistula is formed by a break in the floor of the maxillary
sinus producing a communication between the maxillary sinus and the oral
cavity. Thus, the oral cavity indirectly communicates with the nasal cavity via
the oro-antral fistula and the ostium of the maxillary sinus. An oro-antral fistula
usually arises subsequent to tooth extraction, usually in the maxillary premolar
and molar regions. The clinician often becomes aware of the opening in the
sinus floor during the surgical procedure. Sometimes the communication may
develop a few days after the procedure. The patient frequently complains of
regurgitation of food through the nose while eating and may be aware of air
entering the mouth through the nose during eating and smoking.
2.2.11.5 Increased Mucosal thickness (Mucosal thickening):
The paranasal sinuses mucosa is lined by respiratory epithelium and normally
shows1 mm of thickness.
Nevertheless, the presence of inflammation can develop an increase of 10- to
15-fold in the sinus mucosa thickness.
Mucosal thickening is a characteristic feature in both acute and chronic
sinusitis and a mucosal thickening >3 mm is usually considered pathologic.
2.2.11.6 Genetic, Metabolic & Tumor-like Diseases:
Some of the genetic, metabolic and tumor-like diseases that may
commonly involve the maxillary sinus are osteopetrosis, Paget's disease, fibrous
dysplasia, leontiasis ossea, and giant cell granuloma [11].
18
2.2.11 Clinical considerations about the maxillary sinus:
1. Nerves that supply maxillary teeth are those that supply the maxillary
sinus accounting for dental pain from healthy teeth arising from maxillary
sinusitis.
2. Bone forming the floor of the sinus can also be the bone surrounding the
apex of a tooth. Consequently periapical infection of teeth can spread to
maxillary sinus. The reverse can occur with maxillary sinus infection
being perceived as originating from teeth.
3. Pain from carious lesion or other insults to the dental pulp may be
referred to the sinus.
4. Accidental communication between the sinus and oral cavity may occur
during tooth extraction or surgical procedures leading to oroantral fistula.
5. Roots of maxillary posterior teeth may have close relationship to the floor
of the maxillary sinus. Molars are more related than premolars in the
following order: first molar, second premolar, second and third molars,
first premolar and rarely the canine
6. Most of the lesions of the maxillary sinus are clinically asymptomatic,
especially those localized in the inferior portion of the antrum. These
lesions do not block the free flow of fluid or gas through the ostium and
thus, pressure is not increased within the sinus, conversely, when disease
conditions block the ostium, the stage is set for considerable discomfort
and pain.
7. When maxillary sinus pathoses encroach on neighboring tissues, they
may produce symptoms related to the face, eye, nose and oral cavity. Pain
of the maxillary bone is the most frequent symptom and may be referred
to the face, eye, nose, or Premolar-molar teeth. This may be accompanied
by a vague headache [10].
19
2.2.12. Previous studies:
Previous studies about the maxillary sinus variations were done worldwide.
In a study by Cha et al., using CBCT examinations, the abnormalities found
were signs of acute sinusitis (7.5%), retention cysts (3.5%), and polypoid
mucosal thickening (2.3%) (12).
In two other studies, the prevalence of flat mucosal thickening ranged
from 23.7% to 38.1%, polypoid mucosal thickening ranged from 6.5% to19.4%,
signs of acute sinusitis was 3.6%, and partial and total opacification were 12%
and 7%, respectively[ 13,14].
Also another study found that the Abnormalities were diagnosed in
68.2% of cases. There was a significant difference between genders (p < 0.001)
and there was no difference in age groups. Mucosal thickening was the most
prevalent abnormality (66%), followed by retention cysts (10.1%) and
opacification (7.8%). No association was observed between the proximity of
periapical lesions and the presence and type of inflammatory abnormalities (p =
0.124) [15].
A research by Ahmed A Masri found that the maxillary sinus sizes and
volume showed sexual dimorphism at most gender categories [16]. This study
agreed by Spaeth et al [17].
Some authors have reported differences in the volumes of maxillary
sinuses between males and females [18, 19]. Others have shown no such
differences [20, 21, and 22].
Another radiographic study found that the maxillary sinus septa were
demonstrated in the antra in 19 cases, accessory ostia seen and present in110
cases [23]
Also another studies observed a septa prevalence of 27 %[ 24], Krennmaier
et al found 16% [25], Velasquez-Plata et al found 22% [26] and Kim et al found
26.5% [27].
20
Hypoplasia of the maxillary sinus, which showed by PEREZ et al was
present in 6±3% of cases [8], was reported in 10±4% of cases by Bolger et al [28].
Maxillary sinus pneumatization was the most common anatomic variation
detected, observed in 416 patients (83.2%) and Maxillary sinus hypoplasia was
apparent in only 24 cases (4.8%) [9].
21
Chapter Three
Materials and
Methods
7
3. Methodology and material
3.1.
Study design: observational Descriptive cross sectional hospital based study.
3.2. Study area: in Khartoum State, Sudan.
3.3. Study population: Patients attended at the radiology centers for elective CT scan of the head
regardless of the indication.
3.4. Study duration: from April to Nov 2014
3.5. Inclusion criteria:-
1. Patients without trauma in the head.
2. Patients without trauma in the face.
3. Patients without ENT Operation.
3.6. Exclusion criteria:
1. Patients with trauma in the head.
2. Patients with trauma in the face.
3. Patients with ENT Operation.
4. Refusal of the patient to be enrolled in the study.
3.7. Sampling type and size:
1. Sample Type: Simple random sample.
2. Sample Size: 30 patients.
3.8. Data collection:
Data will be collected from registered CT scan by self-administered
questionnaire.
3.9. Data analysis:
Data will be analysis by SPSS (social package for statically science).
22
3.10. Data Collection Tools:
Self-administered questionnaire and checklist analyzing
3.11. data analysis:
By using statistical package of social science. version 19 (SPSS)
3.11. Ethical considerations:1. Ethical clearance had been obtained from the authorities of the faculty of
graduate studies – The National Ribat University.
2. All participants had a verbal consent and the purpose of the study had
been explained.
3. Participation in the study was completely voluntary for the patients, after
full explanation of the research requirement.
23
Chapter Four
Results
22
4. Results
Thirty axial CT radiographs of 16 sinusitis patients and 14 normal
persons were studied to evaluate the maxillary air sinuses see (Table4.1and Fig
4.1) .Out of 30 participants, 23were female’s and 7 were males, of different age
groups and from different origin see (Tables 4.2, 4.3 and fig 4.2, 4.3). The
participants were classified into 7 age groups decade wise (Table 4.2).
Mucosal thickness was observed in 12persons (40%) of Rt maxillary air sinus, 4
persons (13.3%) showed septum, one person (3.3%) showed obliterated sinus
and one showed mucosal polyp (3.3%), see (Table4.4and fig 4.4).
In the Lt maxillary air sinus mucosal thickness was observed in 8 persons
(26.7%), 3 persons (10.0%) showed septum, 4 persons (13.3%) obliterated
sinuses, see (table 4.5 and fig 4.5)
Fifty percent of study group showed symmetrical maxillary sinus of both
sides. See (Table 4.6 and fig 4.6)
Mucosal thickness was observed to be more common between age 31to50
years of both Rt and Lt sinuses, see (Tables4.7 and 4.8).
Five out of 16sinusities pts in the Lt maxillary sinus were observed to show
increased mucosal thickness, 3 were obliterated sinuses, one septated and 7
normal.
In normal persons mucosal thickness were observed in 3, 2 septated, 1oblitrated
and 8showed normal sinuses (Table 4.9)
Although the mucosal thicknesses were common abnormality in sinusitis
patients, but its statistically insignificant (p<0.05) (p =620).
Nine out of 16sinusities pts in the Rt maxillary sinus were observed to show
increased mucosal thickness, 2 septated, and 5 normal.
In normal persons mucosal thickness were observed in 3, 2 septated, 1oblitrated,
polyp and 7showed normal sinuses (Table 4.10)
Although the mucosal thicknesses were common abnormality in sinusitis
patients, but its statistically insignificant (p0.05) (p.265).
24
In sinusitis patients in RT maxillary sinus 9out of 16 showed
asymmetrical sinuses and 7symitrical while in normal persons 6 asymmetry and
8 symmetrical (Table 4.11).
Also this result showed p value of (0.358) which was statistically insignificant.
In females 9 normal in the Rt and 10 in the Lt, 9 showed mucosal thickness in
Rt sinus and 7in Lt sinus , septated sinus 4inthe Rt and 3 in the Lt,1 obliterated
in the Rt and 3in the Lt sinus (Table4.13and 4.14)
In males, 3normal in Rt maxillary sinus and 5 in the Lt, 3 showed
mucosal thickness in the Rt sinus and 1in the Lt, 1oblitrated in the Lt sinus
(Table4.13and 4.14)
Also there is no relation between the anatomical variations of the
maxillary sinus and the gender, age, residency, occupation.
25
Table (4.1); distribution of sinusitis patients and normal persons
Study
population
Frequency
Percent
sinusitis
16
53.3
normal
14
46.7
Total
30
100.0
16
15.5
15
14.5
14
13.5
13
sinusitis
normal
Fig (4.1); distribution of sinusitis patients and normal persons
26
Table (4.2); Distribution of age among study population
Age
groups(years)
10-20
21-30
31-40
41-50
51-60
61-70
Total
Frequency
5
7
8
5
3
2
30
Percent
16.7
23.3
26.7
16.7
10.0
6.7
100.0
8
7
6
5
4
3
2
1
0
10 to20
21-30
31-40
41-50
51-60
61-70
Fig (4.2): Distribution of age among study population
27
Table (4.3); Original home distribution among study population:
O. home
Frequency
Percent
North
10
33.3
West
13
43.3
East
7
23.3
Total
30
100.0
14
12
10
8
6
4
2
0
north
west
east
Figure (4.3); Original home distributions among study population:
28
Table (4.4); distribution of gender among study group:
Sex
Frequency
Percent
Male
7
23.3
female
23
76.7
Total
30
100.0
25
20
15
10
5
0
male
female
Fig (4.4); distribution of gender among study group:
29
Table (4.5); Maxillary.Rt sinus distribution:
MAXILLARY.RT
Frequency
Percent
Normal
12
40.0
Obliterated
1
3.3
Septated
4
13.3
Mucosal thickness
12
40.0
Polyp
1
3.3
Total
30
100.0
12
10
8
6
4
2
0
normal
obliterated
septated
mucosal
thickness
Figure (4.5); Maxillary. Rt sinus distribution:
30
polyp
Table (4.6); Maxillary Lt sinus distribution:
Maxillary Lt sinus
Frequency
Percent
Normal
15
50.0
Obliterated
4
13.3
Septated
3
10.0
Mucosal thickness
8
26.7
Total
30
100.0
16
14
12
10
8
6
4
2
0
normal
oblitreated
septated
Figure 4.6; Maxillary Lt sinus distribution:
31
mucosal
thickness
Table 4.7; distribution of symmetry of the maxillary sinuses:
Maxillary
Frequency
Percent
sinuses
symmetrical
15
50.0
asymmetry
15
50.0
Total
30
100.0
16
14
12
10
8
6
4
2
0
symmetrical
asymmetry
Fig 4.7; distribution of symmetry of the maxillary sinuses:
32
Table (4.8); Distribution of values of maxillary Rt sinus variations at
different age groups:
Age
groups
normal
MAXILLARY.RT
obliterated septated
mucosal
thickness
Total
Polyp
10-20
3
0
1
0
1
5
21-30
5
0
1
1
0
7
31-40
0
1
2
5
0
8
41-50
1
0
0
4
0
5
51-60
2
0
0
1
0
3
61-70
1
0
0
1
0
2
Total
12
1
4
12
1
30
Table (4.9); Distribution of values of maxillary Lt sinus variations at
different age groups:
Age
MAXILLARY.LT
Total
normal
obliterated
septated
mucosal thickness
10-20
4
0
0
1
5
21-30
3
2
1
1
7
31-40
3
0
1
4
8
41-50
0
2
1
2
5
51-60
3
0
0
0
3
61-70
2
0
0
0
2
Total
15
4
3
8
30
33
Table 4.10; Maxillary Rt sinus variations in relation to sinusitis:
Study
population
MAXILLARY.RT
normal oblitera septated mucosal
ted
thickness
Total
polyp
Sinusitis
5
0
2
9
0
16
normal
7
1
2
3
1
14
12
1
4
12
1
30
Total
Table 4.11; Symmetry of the Rt maxillary sinus in relation to sinusitis:
Study
population
Rt maxillary sinus
Total
symmetrical asymmetry
Sinusitis
7
9
16
normal
8
6
14
15
15
30
Total
34
Table 4.12; maxillary Rt sinus variation in relation to gender:
Gender
MAXILLARY.RT
normal obliterated septated
Total
mucosal
thickness
polyp
male
3
0
0
3
1
7
female
9
1
4
9
0
23
12
1
4
12
1
30
Total
Table 4.13 maxillary Lt sinus variation in relation to gender
Gender
MAXILLARY.LT
normal oblitreated septated
Total
mucosal
thickness
male
5
1
0
1
7
female
10
3
3
7
23
Total
15
4
3
8
30
35
Chapter Five
Discussion
24
5. Discussion
Paranasal sinuses are groups of air-filled spaces developed as expansions of
the nasal cavities eroding the adjacent bone structures. Anatomical
variations, in association with their inherent conditions, were found to be
risk factors for many respiratory tract pathological conditions. Therefore,
identifying these variations has recently been critical for clinical practice.
Paranasal sinus anatomy and variations have gained interest with the
introduction of functional endoscopic sinus surgery and the knowledge of
anatomical variations is most important in the surgical management and
specifically in the prevention of complications. The acquisition of an
excellent definition of the sinus anatomy for a preoperative endoscopic
evaluation can be done by means of computed tomography that is the gold
standard in the study of such structures, for providing accurate information
on soft tissues, bone structures and air, thus characterizing a highly sensitive
imaging.
Discussion regarding the prevalence and clinical significance of maxillary
sinus bony anatomic variations and mucosal abnormalities is included as a
guide to assist the otolaryngologist, radiologist and maxillofacial surgeons in
the evaluation of coronal sinus CT scans method.
In this study, the mucosal thickening was found to be the most common
abnormality (40%) of Rt maxillary sinus and (26.7%) of Lt maxillary air sinus,
it was detected to be more common between age 31to50 years and it was
observed on both normal people and sinusitis patients.
This result agrees with study done in Brazil by Rege et al [15] who found
mucosal thickening was the most prevalent abnormality (66%), and also agrees
with Lana et al [9] who detected (62.6%) and Y. K. Maru, V. Gupta they detected
(70.4%).
36
A study by Lana et al(9) found that It is important to emphasize that antral septa,
detected in almost half of the CBCT exams evaluated, might increase the risk of
sinus membrane perforation during the maxillary sinus floor elevation surgery
which can lead to development of acute or chronic sinusitis.
This study agree with him as we detected antral septa in (13.3%) of Rt
maxillary sinus and (10.0 %) of Lt maxillary air sinus.
Obliterated sinus showed in the Rt maxillary sinus (3.3%) and (13.3%) of Lt
maxillary air sinus this result agree also with Lana et al who detected (1.8%).
Mucosal polyp (3.3%) showed in the Rt maxillary sinus, less than Lana et al (9)
who detected (21.4%).
There was no significant difference between genders (p < 0.001) this finding
disagree with Rege et al [15] and there was no difference in age groups which
agreed by the same author.
The anatomical variations detected in this study were observed on both normal
and sinusitis patients with an equal prevalence. Thus, the presence of anatomic
variations, singly or in combination, does not represent a disease state per se.
This finding was agreed with John Earwaker [29].
Table 5.1; Comparison between present study and other studies:
different studies
mucosal
thickening
Rege et al
66%
Lana et al
62.6%
Y.K.Maru,V.Gupta 70.4%
Present study
66.7%
Antral
septa
……
44.4%
6.6%
23.3%
37
Obliterated
sinus
7.8%
1.8%
25.4%
16.6%
Mucosal
polyp
5.6%
21.4%
……
3.3%
Chapter Six
Conclusion and
Recommendation
36
6. Conclusions & Recommendations
6.1. Conclusions: In conclusion, common anatomic variations of maxillary air sinuses in
this study are mucosal thickening, asymmetry sinuses, antral septa ,
oplitrated sinuses, and polyp.
 The most common variation observed in this study is mucosal
thickening.
 From the results there is no significant between male and female.
 Also there is no difference between age groups.
 Results of this study agree with results of previous studies done
worldwide.
6.2. Recommendations: Otolaryngologists, dentistry, radiologist and anatomist should be aware
about the anatomical variations of the maxillary sinuses.
 Further studies should do in Sudan including large sample size and new
method technique.
 Every patient under gone FESS should do CT.
38
Chapter Sevevn
References
38
7. References
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2- Reddy UM, Dev B. Pictorial essay. Anatomical variations of paranasal
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3-Gerard J, Mark T.Principles of Human Anatomy: 2012. Twelve Edition.
201.
4-Chummy S. lasts Anatomy regional and applied. 2006. Eleventh Edition.
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5-Standring S. Gray’s Anatomy: The Anatomical Basis of clinical
Practice2008.40th Edition. 590
6- Elizabeth J. Akesson, Jacques A. Loeb Linda, Wilson-Pauwels.
Thompson's Core Textbook of Anatomy. 2008. Second Edition.403-404
7- Jorissen M, Hermans R, Bertrand B, Eloy P. Anatomical variations and
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41
Appendix
42
The National Ribat University
Faculty of Graduate Studies
Questionnaire
Anatomical variations & abnormalities of maxillary sinuses on computed
tomography in Sudanese people
1-personal data :
a) Name:……………………………………………………………………
b) Age:………………………………………………………………
c) Sex :
Male
Female
e) Residency………………………………………………………………
f) Occupation:… ……………… ……………………………………
g) Original Home:……………………………………………………
2-past medical History:
a) Sinusitis
Yes
No
b) Facial trauma
Yes
No
c) ENT operation
Yes
No
3-Coronal CT findings
I) Maxillary sinus symmetry
Yes
No
II) Maxillary sinus Rt
a) Maxillary sinus obliteration
Yes
No
b) Presence of antral septum
Yes
No
c) Mucosal thickening
39
Yes
d) Mucosal polyp
Yes
No
No
III) Maxillary sinus Lt
a) Maxillary sinus obliteration
Yes
N0
b) Presence of antral septum
Yes
No
c) Mucosal thickening
Yes
No
d) Mucosal polyp
Yes
No
40