- Email: [email protected]
Use of Radiopaque Solutions in the Diagnosis of Pathologic Conditions of the Maxillary Sinus
USE OF RADIOPAQUE SOLUTIONS IN THE DIAGNOSIS OF PATHOLOGIC CONDITIONS OF THE MAXILLARY SINUS By A R T H U R W . V O N D E IL E N , D .D .S., M .S.D ., A tla n tic C ity, N . J.
IA G N O S IS undoubtedly presents the greatest problem to be found in any of the medical or dental sciences. T o arrive at a correct diagnosis, the proper weighing of all the facts in the case is necessary. T h is is notably true in the diagnosis of disease conditions of the m axillary sinus. T h ere are so many variations in the shape of the normal
out w ith mucoperiosteum equipped with cilia which wave secretions toward the hiatus semilunaris and out into the nose. T h is article is not concerned w ith the acute conditions of the maxillary sinus. T hese may be diagnosed by the roentgen rays and by observation of the clinical symptoms. W h a t is perhaps more impor tan t is the diagnosis of chronic condi-
D
a
b
c
d
e
Fig. 1 (Case 1 ).— Supposed antral cyst, before and after injection of lipiodol. Arrows in a show location of supposed cyst, c, d and e show antrum after injection. Complete filling of the antrum shows no cyst present. Thickening of the membrane may be noted.
sinus th at one is at a loss, at times, to distinguish the normal from the abnor mal. T h e m axillary sinus is a cavity which lies in the maxilla. I t is in form roughly pyramidal, the apex lying tow ard the m alar bone and the base formed by the lateral w all of the nose. T h e hiatus semilunaris, the opening which connects the sinus w ith the nasal cavity, lies high up in the nasal w all of the sinus and opens under the middle turbinate bone in the nose. T h e antrum is sometimes divided into two or more parts by incom plete bony septums. I t is lined throughJour. A. D. A., February, 1933
tions, polypoid degeneration and also the presence of antral cysts. Because of the proximity of the tooth apices to the floor of the sinus, there is great possibility of radicular or root cysts pushing their way into it. In some cases, when this happens, the diagnosis, if the cyst cannot be traced directly to the root of the tooth, is ob scure because of the possibility that antral septums are present. Some method must be used that clearly differentiates the antral cyst from a sinus divided by a septum, and clearly demonstrates the thickened antral membrane found in chronic sinus infection.
284
Von D ellen— Radiopaque Solutions Shambaugh ,1 in describing chronic an tral infection says: By chronic sinusitis, w e understand the de velopment of permanent changes in the membrane lining the antrum. T hese per manent changes are usually the result of an acute inflammatory process which has be come persistent, usually because of inade quate drainage and ventilation through the normal opening. Chronic sinus infection may also be produced through neglected apical disease. Some of these chronic alterations in the membrane lin in g the antrum are not the result o f a persisting acute infection pro longed through faulty drainage; nor are they of dental origin. T hese are the cases in which there is a polypoid degeneration of
Fig. 2 (Case X).— Antrum (indicated by arrows) filled with radiopaque solution.
285
P roetz ,2 in his book on the subject, de scribes his displacement method of inject ing the sinuses with a radiopaque solu tion, which I think is applicable only when all the sinuses are under examina tion. W hen one of the m axillary an trum s is under suspicion, it is much sim pler and less confusing to inject the solution directly into that cavity itself. T h e solution to be injected is one of the halogenated oils. In 1922, Forestier and Sicard 3 discovered th at halogen com pounds of certain oils were inert and radiopaque, and could be injected into
Fig. 3 (Case 1 ).—Lateral view of case.
the membranes lining the antrum quite like the condition of nasal polypi involvin g the nasal mucosa. Such cases are not associated with a purulent discharge except as they may become the seat of an intercurrent in fection.
various body cavities w ithout danger. Ennis 4 states, in a recent article: “T h e iodized oils are nonirritant, sterilized, radiopaque fluids which may be injected
By use of radiopaque solutions injected into the sinus under suspicion, the antral cyst, the thickened membrane, the area of polypoid degeneration of chronic in fection and the antrum s divided by sep tums may be clearly and positively dem onstrated.
2. Proetz: Displacem ent Method of Sinus D iagnosis and Treatm ent, St. Louis: Annals Publishing Co., 1931.
X. Shambaugh, G. E.: Infection of M axil lary Sinus, J. A. D . A., 16:773 (M ay) 1929.
3. Forestier, J., and Sicard J. A .: Methode G enerale d’exploration Radiologique par l’huile iodee. Bull, et mém. Soc. méd. d. hôp. de Paris 46:463 (M arch 17) 1922. 4. Ennis, L. M .: U tilization of Radio paque Solutions in Determ ining Final Inter pretations of Oral Lesions, J. A. D. A., 19:918 (June) 1932.
286
T h e Journal of the American D ental Association
into the sinuses w ithout causing pain; and, as they are readily absorbed by the tissues, they may be allowed to remain in the injected area indefinitely.” P roetz 2 also describes using them in the treat m ent of chronic sinus disease because of their lubricant properties. Lipiodol is the oil th at is chiefly used, but there are other halogen compounds which are fixed iodin or bromin com pounds of some bland vegetable oils. Lipiodol is a fixed compound of iodin,
to enter the antrum with a heavy gage needle through the canine fossa. Careful sterilization of the mucous membrane is necessary because of the risk of antral in fection. T his possibility is slight if due precautions are taken, A point is selected anterior to the cuspid root and above the lateral root in the canine fossa. T h e nee dle is inserted through the overlying tis sue to the bone and, w ith a sharp blow w ith a mallet, the eggshell thickness of bone over the antrum is pierced, the
a b c d e Fig. 4 (Case 2 ).— Supposed antral cyst, indicated by arrows in a and b. Lipiodol was in jected and, in c and d , the cyst was revealed, e shows the condition present after the tooth w as extracted and before lipiodol w as injected to reveal cyst.
Fig. 5. (Case 2 ).— Occlusal view of case. Arrows point to the antrum involved. This picture was taken after injection of lipiodol.
the product of the combination of red poppy seed oil w ith 40 per cent pure metalloid iodin by weight. These oils may be diluted to as much as 50 per cent w ith liquid petroleum for injection into the sinuses. T E C H N IC FOR IN JE C T IO N
T h e simpler the technic used, the bet ter. I t is a comparatively simple m atter
point of the needle entering the antrum . T h e needle best suited for this purpose is of the trocar and cannula type, about 16 or 18 gage. A glass syringe is then fitted to the needle and about 3 to 4 c.c. of the radiopaque solution injected. T he roentgenograms are then made w ithout moving the patient. Several authors describe placing a 16gage steel Cannula in the nose and filling the sinuses through the middle meatus. T h is is hardly practical in the general run of cases because of obstruction of the path that the cannula must take and the difficulty of finding the hiatus semilu naris. P roetz 2 confirms this opinion. REPORT OF CASES
1.—Figures 1 and 2 show a case referred by a dentist, showing, to his mind, an antral cyst. As this diagnosis w as not accepted, a radiopaque solution was injected through the canine fossa into the sinus under examination. T h e results of this procedure are shown in Figures 3 and 4. T h e m axil C a se
W ilson— Failure in Partial D enture Service lary sinus and supposed cyst cavity shown in Figure 1 are, in Figure 3, completely filled with lipiodol. T h is shows that there is a direct communication between the tw o and that there is, therefore, no cyst cavity present. T h e cystic appearance in Figure 1 must have been caused by incomplete bony septums in the antrum. T h e thickened antral mem brane in Figures 3 and 4 can be observed (i.e., the obvious space between the lipiodol and the bony w all of the antrum, a space which must have been occupied by the diseased membrane). Another view of the space occupied by the thickened membrane is also shown in Figure 5. T h is series tends to prove that this sinus is not cystic, but, because of the thickened membrane present, is probably the seat of a chronic infection. T h e clinical exam ina tion of the patient also substantiated the view of chronic antral disease. Figures 6 and 7 are extra-oral view s of this case. Figure 6 shows the right antrum filled with the radiopaque solution. Figure 7 shows a lateral view of the same condi tion. C a s e 2 . — Figures 8 and 9 show a case referred by a dentist as an antral cyst. By careful examination, a suspicious area above the second molar roots can be detected, the first molar being missing. T h is looks like a cyst o f some type, but is .very indefinite. It would be unwise to operate on such evidence.
287
T o help substantiate the diagnosis, lipiodol was injected and the cyst revealed. (Figures 10 and 11.) T he curved outline of the cyst and the absence of a thickened mem brane in the sinus are evident. The antral membrane in this case appears normal. In this instance, the second molar, because of clinical symptoms, had to be extracted. Therefore, the lipiodol w as injected into the antrum through the socket of the extracted tooth. Figure 12 w as taken after this tooth w as extracted and before the lipiodol w as injected. Figure 13 is an occlusal v iew of the case. On the left side, the outline of the cyst is visible. T h is picture w as taken after the injection of the lipiodol.
I have selected the two foregoing cases as I think that they amply illustrate the point that I am desirous of making. By this technic, many difficulties w ill be eliminated and many mistakes in diag nosis prevented. Its simplicity and ease of manipulation, together w ith certainty of results, should certainly result in its more widespread employment. I have never seen any harm result from the em ployment of this technic, and the non irritan t properties of these solutions should certainly not be overlooked. 1910 Pacific Avenue.
SOME COMMON CAUSES OF FAILURE IN PARTIAL D ENTURE SERVICE* By GEORGE W. WILSON, B.S., D.D.S., F.A.C.D., Milwaukee, Wis. R E V IE W of dental literature of the past decade gives sufficient evi dence to establish the fact that the technic of constructing partial dentures has not suffered from lack of attention by
A
♦Read before the Section on P artial D en ture Prosthesis at the Seventy-Fourth Annual Session of the American Dental Association, Buffalo, N. Y., Sept. 14, 1932.
Jour. A. D. A., February, 1933
the dental profession. A host of eminent technicians interested in contributing to the welfare of human comfort and the prolongation of life, as well as the satis faction which evolves from professional service, have labored earnestly and un selfishly. T h e ir diligent and earnest efforts have effected a marked im
IA G N O S IS undoubtedly presents the greatest problem to be found in any of the medical or dental sciences. T o arrive at a correct diagnosis, the proper weighing of all the facts in the case is necessary. T h is is notably true in the diagnosis of disease conditions of the m axillary sinus. T h ere are so many variations in the shape of the normal
out w ith mucoperiosteum equipped with cilia which wave secretions toward the hiatus semilunaris and out into the nose. T h is article is not concerned w ith the acute conditions of the maxillary sinus. T hese may be diagnosed by the roentgen rays and by observation of the clinical symptoms. W h a t is perhaps more impor tan t is the diagnosis of chronic condi-
D
a
b
c
d
e
Fig. 1 (Case 1 ).— Supposed antral cyst, before and after injection of lipiodol. Arrows in a show location of supposed cyst, c, d and e show antrum after injection. Complete filling of the antrum shows no cyst present. Thickening of the membrane may be noted.
sinus th at one is at a loss, at times, to distinguish the normal from the abnor mal. T h e m axillary sinus is a cavity which lies in the maxilla. I t is in form roughly pyramidal, the apex lying tow ard the m alar bone and the base formed by the lateral w all of the nose. T h e hiatus semilunaris, the opening which connects the sinus w ith the nasal cavity, lies high up in the nasal w all of the sinus and opens under the middle turbinate bone in the nose. T h e antrum is sometimes divided into two or more parts by incom plete bony septums. I t is lined throughJour. A. D. A., February, 1933
tions, polypoid degeneration and also the presence of antral cysts. Because of the proximity of the tooth apices to the floor of the sinus, there is great possibility of radicular or root cysts pushing their way into it. In some cases, when this happens, the diagnosis, if the cyst cannot be traced directly to the root of the tooth, is ob scure because of the possibility that antral septums are present. Some method must be used that clearly differentiates the antral cyst from a sinus divided by a septum, and clearly demonstrates the thickened antral membrane found in chronic sinus infection.
284
Von D ellen— Radiopaque Solutions Shambaugh ,1 in describing chronic an tral infection says: By chronic sinusitis, w e understand the de velopment of permanent changes in the membrane lining the antrum. T hese per manent changes are usually the result of an acute inflammatory process which has be come persistent, usually because of inade quate drainage and ventilation through the normal opening. Chronic sinus infection may also be produced through neglected apical disease. Some of these chronic alterations in the membrane lin in g the antrum are not the result o f a persisting acute infection pro longed through faulty drainage; nor are they of dental origin. T hese are the cases in which there is a polypoid degeneration of
Fig. 2 (Case X).— Antrum (indicated by arrows) filled with radiopaque solution.
285
P roetz ,2 in his book on the subject, de scribes his displacement method of inject ing the sinuses with a radiopaque solu tion, which I think is applicable only when all the sinuses are under examina tion. W hen one of the m axillary an trum s is under suspicion, it is much sim pler and less confusing to inject the solution directly into that cavity itself. T h e solution to be injected is one of the halogenated oils. In 1922, Forestier and Sicard 3 discovered th at halogen com pounds of certain oils were inert and radiopaque, and could be injected into
Fig. 3 (Case 1 ).—Lateral view of case.
the membranes lining the antrum quite like the condition of nasal polypi involvin g the nasal mucosa. Such cases are not associated with a purulent discharge except as they may become the seat of an intercurrent in fection.
various body cavities w ithout danger. Ennis 4 states, in a recent article: “T h e iodized oils are nonirritant, sterilized, radiopaque fluids which may be injected
By use of radiopaque solutions injected into the sinus under suspicion, the antral cyst, the thickened membrane, the area of polypoid degeneration of chronic in fection and the antrum s divided by sep tums may be clearly and positively dem onstrated.
2. Proetz: Displacem ent Method of Sinus D iagnosis and Treatm ent, St. Louis: Annals Publishing Co., 1931.
X. Shambaugh, G. E.: Infection of M axil lary Sinus, J. A. D . A., 16:773 (M ay) 1929.
3. Forestier, J., and Sicard J. A .: Methode G enerale d’exploration Radiologique par l’huile iodee. Bull, et mém. Soc. méd. d. hôp. de Paris 46:463 (M arch 17) 1922. 4. Ennis, L. M .: U tilization of Radio paque Solutions in Determ ining Final Inter pretations of Oral Lesions, J. A. D. A., 19:918 (June) 1932.
286
T h e Journal of the American D ental Association
into the sinuses w ithout causing pain; and, as they are readily absorbed by the tissues, they may be allowed to remain in the injected area indefinitely.” P roetz 2 also describes using them in the treat m ent of chronic sinus disease because of their lubricant properties. Lipiodol is the oil th at is chiefly used, but there are other halogen compounds which are fixed iodin or bromin com pounds of some bland vegetable oils. Lipiodol is a fixed compound of iodin,
to enter the antrum with a heavy gage needle through the canine fossa. Careful sterilization of the mucous membrane is necessary because of the risk of antral in fection. T his possibility is slight if due precautions are taken, A point is selected anterior to the cuspid root and above the lateral root in the canine fossa. T h e nee dle is inserted through the overlying tis sue to the bone and, w ith a sharp blow w ith a mallet, the eggshell thickness of bone over the antrum is pierced, the
a b c d e Fig. 4 (Case 2 ).— Supposed antral cyst, indicated by arrows in a and b. Lipiodol was in jected and, in c and d , the cyst was revealed, e shows the condition present after the tooth w as extracted and before lipiodol w as injected to reveal cyst.
Fig. 5. (Case 2 ).— Occlusal view of case. Arrows point to the antrum involved. This picture was taken after injection of lipiodol.
the product of the combination of red poppy seed oil w ith 40 per cent pure metalloid iodin by weight. These oils may be diluted to as much as 50 per cent w ith liquid petroleum for injection into the sinuses. T E C H N IC FOR IN JE C T IO N
T h e simpler the technic used, the bet ter. I t is a comparatively simple m atter
point of the needle entering the antrum . T h e needle best suited for this purpose is of the trocar and cannula type, about 16 or 18 gage. A glass syringe is then fitted to the needle and about 3 to 4 c.c. of the radiopaque solution injected. T he roentgenograms are then made w ithout moving the patient. Several authors describe placing a 16gage steel Cannula in the nose and filling the sinuses through the middle meatus. T h is is hardly practical in the general run of cases because of obstruction of the path that the cannula must take and the difficulty of finding the hiatus semilu naris. P roetz 2 confirms this opinion. REPORT OF CASES
1.—Figures 1 and 2 show a case referred by a dentist, showing, to his mind, an antral cyst. As this diagnosis w as not accepted, a radiopaque solution was injected through the canine fossa into the sinus under examination. T h e results of this procedure are shown in Figures 3 and 4. T h e m axil C a se
W ilson— Failure in Partial D enture Service lary sinus and supposed cyst cavity shown in Figure 1 are, in Figure 3, completely filled with lipiodol. T h is shows that there is a direct communication between the tw o and that there is, therefore, no cyst cavity present. T h e cystic appearance in Figure 1 must have been caused by incomplete bony septums in the antrum. T h e thickened antral mem brane in Figures 3 and 4 can be observed (i.e., the obvious space between the lipiodol and the bony w all of the antrum, a space which must have been occupied by the diseased membrane). Another view of the space occupied by the thickened membrane is also shown in Figure 5. T h is series tends to prove that this sinus is not cystic, but, because of the thickened membrane present, is probably the seat of a chronic infection. T h e clinical exam ina tion of the patient also substantiated the view of chronic antral disease. Figures 6 and 7 are extra-oral view s of this case. Figure 6 shows the right antrum filled with the radiopaque solution. Figure 7 shows a lateral view of the same condi tion. C a s e 2 . — Figures 8 and 9 show a case referred by a dentist as an antral cyst. By careful examination, a suspicious area above the second molar roots can be detected, the first molar being missing. T h is looks like a cyst o f some type, but is .very indefinite. It would be unwise to operate on such evidence.
287
T o help substantiate the diagnosis, lipiodol was injected and the cyst revealed. (Figures 10 and 11.) T he curved outline of the cyst and the absence of a thickened mem brane in the sinus are evident. The antral membrane in this case appears normal. In this instance, the second molar, because of clinical symptoms, had to be extracted. Therefore, the lipiodol w as injected into the antrum through the socket of the extracted tooth. Figure 12 w as taken after this tooth w as extracted and before the lipiodol w as injected. Figure 13 is an occlusal v iew of the case. On the left side, the outline of the cyst is visible. T h is picture w as taken after the injection of the lipiodol.
I have selected the two foregoing cases as I think that they amply illustrate the point that I am desirous of making. By this technic, many difficulties w ill be eliminated and many mistakes in diag nosis prevented. Its simplicity and ease of manipulation, together w ith certainty of results, should certainly result in its more widespread employment. I have never seen any harm result from the em ployment of this technic, and the non irritan t properties of these solutions should certainly not be overlooked. 1910 Pacific Avenue.
SOME COMMON CAUSES OF FAILURE IN PARTIAL D ENTURE SERVICE* By GEORGE W. WILSON, B.S., D.D.S., F.A.C.D., Milwaukee, Wis. R E V IE W of dental literature of the past decade gives sufficient evi dence to establish the fact that the technic of constructing partial dentures has not suffered from lack of attention by
A
♦Read before the Section on P artial D en ture Prosthesis at the Seventy-Fourth Annual Session of the American Dental Association, Buffalo, N. Y., Sept. 14, 1932.
Jour. A. D. A., February, 1933
the dental profession. A host of eminent technicians interested in contributing to the welfare of human comfort and the prolongation of life, as well as the satis faction which evolves from professional service, have labored earnestly and un selfishly. T h e ir diligent and earnest efforts have effected a marked im