Case Report
Volume 3 Issue 6 - 2016
Unusual Case of Maxillary Antrum Obliteration Secondary to Cyst Removal: A Case Report and Review of Literature
Simon Chummar*
Dental Department, NMC Specialty Hospital, Dubai, UAE
*Corresponding Author:Dr. Simon Chummar, Dental Department, NMC Specialty Hospital, PB-7832, Dubai, UAE.
Received: January 20, 2016; Published: February 27, 2016
Citation: Simon Chummar. “Unusual Case of Maxillary Antrum Obliteration Secondary to Cyst Removal-A Case Report and Review of Literature”. EC Dental Science 3.6 (2016): 637-641.
Abstract
Intraluminal osteogenesis of maxillary antrum is very rare. We report a case of Extrinsic cyst (residual cyst) involving the maxillary antrum which was enucleated by Cadwell-luc approach. Six month follow-up showed osteogenesis of the maxillary antrum.
Keywords: Maxillary antrum; Cyst Enuculation; Maxillary sinus obliteration; Osteogenesis; Maxillary sinus Hypoplasia (MSH); Silent sinus syndrome (SSS)
Introduction
Maxillary sinus develops from invagination of the mucous membrane of middle meatus of the nasal cavity at about the 3rd month of intrauterine life. Fully development reaches with the age of 16 years. Enlargement of the sinus is uncommonly encountered, and is produced by air (pneumocele) and mucus (mucocele) entrapment, or by benign tumors. Reduction in size and volume is more frequent. It can be due to Heredo-familial syndromic conditions, neoplastic changes, systemic disorders like sickle cell anemia and osteopetrosis, Fibro-osseous disorders, Midfacial fractures involving the sinus, iatrogenic cause, like direct surgical intervention (Caldwell-Luc procedure), benign odontogenic cysts as they enlarge produce size and shape distortions by external impingement. In this report we present a rare case of florid ossification secondary to residual cyst enuculation by Cadwel-Luc operation. Our literature search has not shown any similar case.
Case Report
A 42 year old female patient fit and healthy reported to the department of maxillofacial surgery with the history mild asymmetry of the face on the left side. She had a history of extraction of 26 four years back at another clinic. She has been noticing a swelling on left side of face since then which was slowly increasing in size. CT scan PNS region showed a residual cystic lesion from 26 involving the left maxillary antrum.
Biopsy was done and Histopathology report was of a radicular cyst. The cyst was enucleated by Cadwell Luc approach under General anesthesia with inferior meatus nasal antrostomy. The area healed uneventfully. The patient was evaluated at 1months, 3 months and 7 months. During her 7 months review it was noted that she had slight odema on the left side of face. A CT Scan was done which showed obliteration of the maxillary antrum
A repeat biopsy was done which showed bone on exploring the antrum with lining which was histopathologically reported as fibrotic tissue with normal oral mucosa.. The patient is under follow-up.

Figure 1a and b: Cyst involving the maxillary antrum.

Figure 2a and b: Bone formation in maxillary antrum.

Discussion
Intraluminal osteogenesis of maxillary antrum has been reported very rarely. The reduction of the size of the maxillary sinus is multifactorial and includes congenital and acquired variants. Among the latter are
1. Fibro osseous lesions,
2. Tumors of maxillary antrum,
3. Trauma resulting in displaced bony fragments
4. Cysts involving the maxillary antrum
We only address those disorders which cause a reduction of the actual bony configuration and anatomic borders of the sinus in this discussion section
Although complete aplasia of the maxillary sinus can occur, it is extremely rare, whereas maxillary sinus hypoplasia (MSH) is a well-known clinical entity and is classified by CT scan. There are three types: MSH-Type I has normally developed uncinate process and well-defined infundibulum with mild-to-moderate hypoplasia, MSH-Type II is characterized by a hypoplastic uncinate process and an ill-defined or absent infundibular passage, and soft tissue opacification of the sinus on CT scan. MSH-Type III shows absence of uncinate process with profound hypoplasia of the sinus, seen only as a shallow cleft. Unilateral and bilateral hypoplasia occurs in less than 10% of patients [6].
Syndromal etiologies of MSH can be broadly divided into lack of development from failure of midfacial skeleton growth and obliteration of the sinus cavities from osteosclerosis. Many forms of craniofacial dysostoses exist, most common being mandibular dysostosis (Treacher-Collins syndrome), Acrocephalosyndactyly (Apert’s syndrome), craniofacial dysostosis (Crouzon’s syndrome), and maxillomandibular dysplasia (Binder’s syndrome). The size of the maxillary sinus is reduced by unilateral hyperplasia of the lateral maxilla and zygoma in Goldenhar’s syndrome. In Williams syndrome, or Elfin Face syndrome paranasal sinuses are small bilaterally due to failure in prenatal and post-natal growth.
MSH is considered to stem from changes in embryologic development, silent sinus syndrome (SSS) is considered to be an acquired disease. Usually the patient is asymptomatic and they suddenly develop enopthalmos or hypoglobus secondary to the collapse of the orbital floor. Obstruction of the natural ostium is thought to be the initiating factor, resulting in hypoventilation and generating a negative pressure causing demineralization and bowing of the walls into the sinus, causing collapse of sinus.
Hematologic conditions like sickle cell anemia and thalassemia affects the marrow space of the facial bones. As with all marrow spaces in the body, the medullary spaces of the maxilla are widened to accommodate the need for increased production of blood cells, leading to a decrease in the volume, or obliteration, of the sinus itself. Maxillary sinus hypoplasia has been reported with primary and acquired hypopituitarism and hypothyroidism. Osteopetrosis (Albers-Schonberg disease, Brittle Bone disease) is a family of heredo-familial disorder, in which a proliferation of abnormally dense bone replaces the normal medullary bone, resulting in marrow space and sinus cavity obliteration [5]. Our patient was free of any systemic disease which could have lead to obliteration of the sinus.
Another greatest source of obliteration of the maxillary sinus was malignant neoplasms arising in the sinus, mainly squamous cell carcinomas. The tumor proliferates in the cavity resulting in the destruction of the wall of the maxillary antrum. As the tumors advances there may be no recognizable sinus, only an irregular soft tissue mass. Malignant tumors arising from the maxillary alveolus may grow into the sinus but generally destroy only its floor, whereas intracavitary tumors have multidirectional growth. The main feature of malignant tumors is an irregular appearing sinus due to the loss of its bony walls, with soft tissue inside.
Benign tumors of the maxillary sinus are extremely rare and include salivary gland neoplasms, inverted papillomas and osteomas, which produce an intracavitary mass which can expand the sinus if large. An exception is the pseudo tumor, which is a chronic inflammatory lesion that can produce extensive destruction and distortion of the maxillary sinus.
Odontogenic growth like radicular cysts arising from the roots of nonvital teeth elevates the antral floor, while developmental (dentigerous, keratocysts) cysts displace the posterior and lateral walls. They don’t destroy the walls of the antrum but expands and create what appears to be a duplicate sinus. Same is the case with Benign odontogenic tumors (myxoma, cementoma, odontoma) which narrow the maxillary sinus by external compression, Only exception being the Ameloblastomas. Although histologically they are benign, but locally invasive and can infiltrate the sinus. Radiographically, the sinus walls may be remodeled, or destroyed. The calcifying epithelial odontogenic tumor (Pindborg tumor) 2 presents similarly. Our case had a radicular cyst initially for which tooth extraction was done after which slowly the cyst enlarged involving the maxillary antrum and destroying the walls of antrum.
Fibro-osseous disorders may broadly be divided into ossifying lesions (osteomas, ossifying fibroma), fibrous dysplasia, and Paget’s disease. The ossifying fibroma (also cementifying fibroma) is an encapsulated benign bony neoplasm that encroaches upon the antrum by mass effect. It arises from the alveolar segment of the maxilla and expands internally towards the sinus rather than deform the outer surface bones. Fibrous dysplasia is an idiopathic skeletal disorder which occurs as a monostotic and polyostotic in which medullary bone is replaced by poorly organized weak fibro-osseous tissue. In the maxilla, the abnormal “woven” bone gradually replaces the normal medullary bone, enlarging the maxilla and progressively obliterating the maxillary sinus cavity. By contrast, in Paget’s disease, or osteitis deformans, the maxilla is enlarged bilaterally, especially in its posterior aspect, by the formation of abnormal bone formed by both osteoclastic and osteoblastic activity. In replacing the normal medullary bone, both sinus cavities become progressively obliterated [1].
Midfacial fractures commonly change maxillary sinus shape and volume by telescoping, or rotation, of bony fragments into the sinus. This is especially true with zygoma fractures”. Orbital floor “blowout” fractures also destroy the roof of the maxillary sinus, and many times lowers the roof into the antrum. There may be areas of bony sclerosis and irregularities in the antrum post reduction of maxillary and zygoma fractures.
The paranasal sinuses possess the idiosyncratic ability to auto-obliterate by osteoneogenesis and fibrosis, following disturbance and removal of their lining especially in Caldwell-Luc operations. This varies in degree with different sinuses, but is most marked in the maxillary and frontal sinuses. In the maxillary sinus, the process progresses medially from the zygomatic recess in varying degrees, producing lateral narrowing to near total obliteration. The condition can be distinguished from developmental hypoplasia by the presence of a surgical defect in the lateral wall and the dense bony sclerosis of the remaining walls. Our case had cyst removal through Caldwell-Luc approach which resulted in florid bone deposition. Our case was unique because the amount of bone deposition was large and florid following a peculiar pattern along the displaced and dissected periosteum. This case proves that periosteum in the maxilla has high regenerative capacity and if used properly can be used for Osseo integration of Implants. The high regenerative capacity of the sinus mucosa and periosteum is made use in sinus lift procedures [4]. Considering the fact that this technique reduces the risks of morbidity related to bone graft harvesting or eliminates the cost of allogenic or synthetic grafting materials.
Calcification with a nodular or linear shape was found with both fungal and non fungal sinusitis; however, fine punctate calcification was found only in fungal sinusitis, while smooth-margined, round, or eggshell type calcification was found exclusively with the non fungal variety [3]. Our patient was not immunocompromised nor did not have any fungal sinusitis.
Conclusion
The maxillary sinus either expands or compresses its walls in response to an internal or external slow growing mass. Aggressive infiltrating lesions will produce bone destruction and will show a mixed radiological pattern of remodeling and erosion. Lesions arising from fibro-osseous disorders, hereditary anemias and bone dysplasias will involve the medullary spaces and progressively obliterate the sinus.
The high frequency of variation seen in the normal and abnormal anatomy of the maxillary sinus, and how this sinus preserves its morphology across polyethnic groups, continues to intrigue the author. While volume differences may vary in diverse populations, there is a relatively uniform response to a multiplicity of stresses across these ethnic boundaries.
Acknowledgement
Dr. Bhushan Jayade MDS, FDSRCS, FFDRCSI for his help in preparing the manuscript and Dr. Shakeel Aktar MD for reviewing the slides.
Bibliography
  1. Lawson W., et al. “The development and pathologic processes that influence maxillary sinus pneumatization”. Anatomical record 291.11 (2008): 1554-1563.
  2. Verbin R and Barnes L. “Cysts and cyst-like lesions in the oral cavity, jaws and neck”. In: Barnes L, editor. “Surgical pathology of the head and neck”. Vol. 2 2nd edn. New York: Marcel Dekker (2000): 1049-1232.
  3. Jung Hwan Yoon., et al. “Calcification in Chronic Maxillary Sinusitis: Comparison of CT Findings with Histopathologic Results”. American Journal of Neuroradiology 20 (1999): 571-574.
  4. Palma VC.,et al. “Bone reformation and implant integration following maxillary sinus membrane elevation: an experimental study in primates”. Clinical implant dentistry and related research1 (2008): 11-24.
  5. Tolar J., et al. “Osteopetrosis”. New England Journal of Medicine 351 (2004): 2839-2849.
  6. Erdem T., et al. “Maxillary sinus hypoplasia”. Rhinology 40 (2002): 150-153.
  7. Khonsari RH., et al. “Silent sinus syndrome associated with intra sinusal ossification”. Revue de Stomatologie et de Chirurgie Maxillo-faciale 111.5-6 (2010): 331-333.
  8. Ronald Alastair Mc neill. “Surgical obliteration of the maxillary sinus: A Clinical and Experimental Study”. The Laryngoscope 77.2 (1967): 202-217.
  9. Sontakke SA., et al. “Mar Computed tomographic features of fibrous dysplasia of maxillofacial region”. Imaging Science in Dentistry 41.1 (2011): 23-28.
  10. Cass A., et al. “Maxillary antrum hypoplasia”. International Journal of Oral and Maxillofacial Surgery 19.3 (1990): 158-159.
Copyright: © 2016 Simon Chummar. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

PubMed Indexed Article


EC Pharmacology and Toxicology
LC-UV-MS and MS/MS Characterize Glutathione Reactivity with Different Isomers (2,2' and 2,4' vs. 4,4') of Methylene Diphenyl-Diisocyanate.

PMID: 31143884 [PubMed]

PMCID: PMC6536005


EC Pharmacology and Toxicology
Alzheimer's Pathogenesis, Metal-Mediated Redox Stress, and Potential Nanotheranostics.

PMID: 31565701 [PubMed]

PMCID: PMC6764777


EC Neurology
Differences in Rate of Cognitive Decline and Caregiver Burden between Alzheimer's Disease and Vascular Dementia: a Retrospective Study.

PMID: 27747317 [PubMed]

PMCID: PMC5065347


EC Pharmacology and Toxicology
Will Blockchain Technology Transform Healthcare and Biomedical Sciences?

PMID: 31460519 [PubMed]

PMCID: PMC6711478


EC Pharmacology and Toxicology
Is it a Prime Time for AI-powered Virtual Drug Screening?

PMID: 30215059 [PubMed]

PMCID: PMC6133253


EC Psychology and Psychiatry
Analysis of Evidence for the Combination of Pro-dopamine Regulator (KB220PAM) and Naltrexone to Prevent Opioid Use Disorder Relapse.

PMID: 30417173 [PubMed]

PMCID: PMC6226033


EC Anaesthesia
Arrest Under Anesthesia - What was the Culprit? A Case Report.

PMID: 30264037 [PubMed]

PMCID: PMC6155992


EC Orthopaedics
Distraction Implantation. A New Technique in Total Joint Arthroplasty and Direct Skeletal Attachment.

PMID: 30198026 [PubMed]

PMCID: PMC6124505


EC Pulmonology and Respiratory Medicine
Prevalence and factors associated with self-reported chronic obstructive pulmonary disease among adults aged 40-79: the National Health and Nutrition Examination Survey (NHANES) 2007-2012.

PMID: 30294723 [PubMed]

PMCID: PMC6169793


EC Dental Science
Important Dental Fiber-Reinforced Composite Molding Compound Breakthroughs

PMID: 29285526 [PubMed]

PMCID: PMC5743211


EC Microbiology
Prevalence of Intestinal Parasites Among HIV Infected and HIV Uninfected Patients Treated at the 1o De Maio Health Centre in Maputo, Mozambique

PMID: 29911204 [PubMed]

PMCID: PMC5999047


EC Microbiology
Macrophages and the Viral Dissemination Super Highway

PMID: 26949751 [PubMed]

PMCID: PMC4774560


EC Microbiology
The Microbiome, Antibiotics, and Health of the Pediatric Population.

PMID: 27390782 [PubMed]

PMCID: PMC4933318


EC Microbiology
Reactive Oxygen Species in HIV Infection

PMID: 28580453 [PubMed]

PMCID: PMC5450819


EC Microbiology
A Review of the CD4 T Cell Contribution to Lung Infection, Inflammation and Repair with a Focus on Wheeze and Asthma in the Pediatric Population

PMID: 26280024 [PubMed]

PMCID: PMC4533840


EC Neurology
Identifying Key Symptoms Differentiating Myalgic Encephalomyelitis and Chronic Fatigue Syndrome from Multiple Sclerosis

PMID: 28066845 [PubMed]

PMCID: PMC5214344


EC Pharmacology and Toxicology
Paradigm Shift is the Normal State of Pharmacology

PMID: 28936490 [PubMed]

PMCID: PMC5604476


EC Neurology
Examining those Meeting IOM Criteria Versus IOM Plus Fibromyalgia

PMID: 28713879 [PubMed]

PMCID: PMC5510658


EC Neurology
Unilateral Frontosphenoid Craniosynostosis: Case Report and a Review of the Literature

PMID: 28133641 [PubMed]

PMCID: PMC5267489


EC Ophthalmology
OCT-Angiography for Non-Invasive Monitoring of Neuronal and Vascular Structure in Mouse Retina: Implication for Characterization of Retinal Neurovascular Coupling

PMID: 29333536 [PubMed]

PMCID: PMC5766278


EC Neurology
Longer Duration of Downslope Treadmill Walking Induces Depression of H-Reflexes Measured during Standing and Walking.

PMID: 31032493 [PubMed]

PMCID: PMC6483108


EC Microbiology
Onchocerciasis in Mozambique: An Unknown Condition for Health Professionals.

PMID: 30957099 [PubMed]

PMCID: PMC6448571


EC Nutrition
Food Insecurity among Households with and without Podoconiosis in East and West Gojjam, Ethiopia.

PMID: 30101228 [PubMed]

PMCID: PMC6086333


EC Ophthalmology
REVIEW. +2 to +3 D. Reading Glasses to Prevent Myopia.

PMID: 31080964 [PubMed]

PMCID: PMC6508883


EC Gynaecology
Biomechanical Mapping of the Female Pelvic Floor: Uterine Prolapse Versus Normal Conditions.

PMID: 31093608 [PubMed]

PMCID: PMC6513001


EC Dental Science
Fiber-Reinforced Composites: A Breakthrough in Practical Clinical Applications with Advanced Wear Resistance for Dental Materials.

PMID: 31552397 [PubMed]

PMCID: PMC6758937


EC Microbiology
Neurocysticercosis in Child Bearing Women: An Overlooked Condition in Mozambique and a Potentially Missed Diagnosis in Women Presenting with Eclampsia.

PMID: 31681909 [PubMed]

PMCID: PMC6824723


EC Microbiology
Molecular Detection of Leptospira spp. in Rodents Trapped in the Mozambique Island City, Nampula Province, Mozambique.

PMID: 31681910 [PubMed]

PMCID: PMC6824726


EC Neurology
Endoplasmic Reticulum-Mitochondrial Cross-Talk in Neurodegenerative and Eye Diseases.

PMID: 31528859 [PubMed]

PMCID: PMC6746603


EC Psychology and Psychiatry
Can Chronic Consumption of Caffeine by Increasing D2/D3 Receptors Offer Benefit to Carriers of the DRD2 A1 Allele in Cocaine Abuse?

PMID: 31276119 [PubMed]

PMCID: PMC6604646


EC Anaesthesia
Real Time Locating Systems and sustainability of Perioperative Efficiency of Anesthesiologists.

PMID: 31406965 [PubMed]

PMCID: PMC6690616


EC Pharmacology and Toxicology
A Pilot STEM Curriculum Designed to Teach High School Students Concepts in Biochemical Engineering and Pharmacology.

PMID: 31517314 [PubMed]

PMCID: PMC6741290


EC Pharmacology and Toxicology
Toxic Mechanisms Underlying Motor Activity Changes Induced by a Mixture of Lead, Arsenic and Manganese.

PMID: 31633124 [PubMed]

PMCID: PMC6800226


EC Neurology
Research Volunteers' Attitudes Toward Chronic Fatigue Syndrome and Myalgic Encephalomyelitis.

PMID: 29662969 [PubMed]

PMCID: PMC5898812


EC Pharmacology and Toxicology
Hyperbaric Oxygen Therapy for Alzheimer's Disease.

PMID: 30215058 [PubMed]

PMCID: PMC6133268


News and Events


August Issue Release

We always feel pleasure to share our updates with you all. Here, notifying you that we have successfully released the August issue of respective journals and can be viewed in the current issue pages.

Submission Deadline for September Issue

Ecronicon delightfully welcomes all the authors around the globe for effective collaboration with an article submission for the September issue of respective journals. Submissions are accepted on/before August 15, 2020.

Certificate of Publication

Ecronicon honors with a "Publication Certificate" to the corresponding author by including the names of co-authors as a token of appreciation for publishing the work with our respective journals.

Best Article of the Issue

Editors of respective journals will always be very much interested in electing one Best Article after each issue release. The authors of the selected article will be honored with a "Best Article of the Issue" certificate.

Certifying for Review

Ecronicon certifies the Editors for their first review done towards the assigned article of the respective journals.

Latest Articles

The latest articles will be updated immediately on the articles in press page of the respective journals.

Immediate Assistance

The prime motto of this team is to clarify all the queries without any delay or hesitation to avoid the inconvenience. For immediate assistance on your queries please don't hesitate to drop an email to editor@ecronicon.uk