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Referral details

Case 115495

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Referral category

Dental implants

Region of interest

Md 35-45

Referral reason

[Only visible to logged-in users]

1 Files Info

Canaray 115495

1. Abrasion on tooth 34

Abrasion is present along the buccal surface of tooth 34, just apical to the level of the cemento-enamel junction.

Periodontal bone loss around tooth 34

Moderate horizontal periodontal bone loss is evident around the root circumference of tooth 34.

Retained root of tooth 44

The crown of tooth 44 appears to be absent. The root of this tooth is retained within the alveolar process. There is no radiographic evidence of periapical or periradicular pathology surrounding this retained root.

3. Opacification of left maxillary sinus + mucocele formation

Both the anterior and posterior compartments of the left maxillary sinus appear completely opacified, including the small loculation located within the septum in the middle of the sinus. The posterior compartment of the sinus has caused a slight expansion of its posterolateral wall, but the wall remains intact. These findings suggest the presence of obstructive sinusitis, with the development of a mucocele in the posterior compartment of the sinus. If the patient is not already under the care of an ENT specialist, a referral may be considered.

2. Double left maxillary antrum

The left maxillary sinus has been separated into distinct anterior and posterior compartments by a bony septum which extends from its medial wall to its lateral wall. A small sinus loculation is also evident within this bony septum. This is a rare anatomic variant.

Axial views of the left maxillary sinus

These axial cross-sectional images demonstrate that the left maxillary sinus appears to be separated into distinct anterior and posterior compartments by a bony septum that extends from its medial wall to its lateral wall. A small sinus loculation has formed within this bony septum. As well, a sinus mucocele may be forming in the posterior compartment of the left maxillary sinus, and the posterolateral wall appears expanded adjacent to this region. The posterolateral wall remains intact, despite this finding.

Coronal views of the left maxillary sinus

These coronal cross-sectional images demonstrate that the left maxillary sinus appears completely opacified. The left ostiomeatal unit is not completely visualized in this imaging volume.

Sagittal views of the left maxillary sinus

These sagittal cross-sectional images demonstrate that the floor of the left maxillary sinus appears intact. Note the presence of a bony septum located within the middle third of the left maxillary sinus, which extends from the orbital floor to the sinus floor. A small sinus loculation has formed within this septum, which also appears opacified.

4. Right maxillary sinusitis

The right maxillary sinus appears completely opacified, which suggests the presence of sinusitis. In spite of this, the walls of the right maxillary sinus appear intact and exhibit a normal thickness and contour.

5. History of sinus surgery

The anterolateral wall of the left maxillary sinus appears focally dehiscent, which likely arose secondary to a history of sinus surgery, such as a Caldwell-Luc procedure. Clinical correlation with the patient's medical history may aid in substantiating this interpretation.

6. Possible history of left middle turbinectomy

The left middle concha is not visualized in this imaging volume, which could suggest a possible history of left middle turbinectomy.

7. Possible left nasal polyp

A round soft tissue mass is evident in the left nasal cavity, which likely represents a nasal polyp. However, examination by an ENT specialist is necessary to substantiate this interpretation.

8. Possible right nasal polyp

A round soft tissue mass is evident in the posterior aspect of the right nasal cavity, which extends posteriorly to encroach the right torus tubarius. Although this likely reflects another nasal polyp, clinical examination by an ENT specialist is necessary to substantiate this interpretation.

9. Sphenoid sinusitis

The sphenoid sinus is partially captured in this imaging volume, and appears completely opacified. This could suggest the presence of sphenoid sinusitis.

10. Right palatine tonsillolith

A tonsillolith is present in the right palatine tonsil. This is an incidental finding with no significance because tonsilloliths exfoliate spontaneously.

11. Moderate cervical degenerative joint disease

Osteophytes and subchondral sclerosis are present in the articulating regions of the cervical vertebrae. The intervertebral joint spaces appear reduced. These findings are suggestive of moderate cervical degenerative joint disease.

12. Calcified stylohyoid ligaments

The stylohyoid ligaments are partially calcified bilaterally. This is an incidental finding with no clinical significance.