Резюме
Побережник Г.А, Омельченко О.А. Морфологічні зміни слизової оболонки гайморової пазухи в залежності від причини верхньощелепного синуситу.
Представлений морфогістохімічний аналіз 120 біоптатів, пацієнтів з різними причинами розвитку одонтогенного верхньощелепного синуситу. Показані і виявлені характерні зміни, обумовлені різними причинами розвитку одонтогенного верхньощелепного синуситу.
Ключові слова: одонтогенний верхньощелепний синусит, слизова оболонка, морфогістохімічені методи.

Резюме
Побережник Г.А, Омельченко О.А. Морфологические изменения слизистой оболочки гайморовой пазухи в зависимости от причины верхнечелюстного синусита.
Представлен морфогистохимический анализ 120 биоптатов, пациентов с различными причинами развития одонтогенного верхнечелюстного синусита. Показаны и выявлены характерные изменения, обусловленные разными причинами развития одонтогенного верхнечелюстного синусита.
Ключевые слова: одонтогенный верхнечелюстной синусит, слизистая оболочка, морфогистохимические методы.

Summary
Poberegnyk G.A., Omelchenko O.A. Morphological changes of mucous membrane of Maxillary sinus depending on reason of maxillary sinusitis.
The morfohistochemical analysis presented 120 biopsies of patients with different causes of odontogenic maxillary sinusitis. Shown and identified characteristic changes due to different causes of odontogenic maxillary sinusitis.
Key words: odontogenic maxillary sinusitis, the mucous membrane, morfohistochemical methods.

УДК 616.31:616.216.1 – 002 – 018.25 - 02

Kharkiv National Medical University

4 Lenin Avenue, Kharkiv,61022,Ukraine

проспект Ленина, 4, Харьков, 61022,Украина 

Харьковский национальный медицинский университет

galina18@ukr.net

Odontogenic maxillary sinusitis is currently one of the major problems of dentistry and maxillofacial surgery. Basing on the data of some authors the mentioned disease can be found in 12,0 – 75,0% of patients with the pathology of maxillary sinuses [1,3,6,10]. Until now, there are still a lot of unsettled issues [1,2,3,4,6,9,10]. One of the main issues is causation of complications or recurrences which occur after operative treatment of maxillary sinus. Over the last years postoperative complications have increased from 30% to 50% [5,6,7,8,9]. Therefore, in order to identify the causes and character of arising complications it is necessary to determine morphohistochemical changes of mucous membrane of maxillary sinus depending on conditions which caused odontogenic maxillitis. The given issue is slightly presented in the literature.

Goal – to investigate morphological changes of mucous membrane of a sinus depending on the cause of maxillary sinusitis.

Materials and methods:

We investigated 120 biopsy samples of mucous membrane of maxillary sinus resulted from maxillary sinusotomy. Material fragments were fixed in 10% formaline and poured in wax for light-optic investigation. Dewaxed sections 5 mcm thick were stained by hematoxylin and eosin, to verify connective tissue fibers van Gieson’s stain was used. In order to identify fibrin and collagen fibers Mallory’s stain was used. Sulphated (рН-1,5) and non-sulphated (рН-3,5) glycosaminoglycans were detected by Romhangi, 1963 (control processing of sections by hyaluronidase).

Microslides were investigated using “Olympus BX-41” microscope with postprocessing using “Olympus DP-soft version 3.1” and Microsoft Excel programs.

Results of investigation and their discussion

The material for the investigation was divided into following groups:

1^st group – patients with odontogenic maxillary sinusitis (OMS) caused by odontogenic cysts.

2^nd group – patients with OMS caused by empyema of odontogenic cyst.

3^rd group – patients with OMS caused by different forms of periodontitis.

4^th  group – patients with OMS caused by foreign body in the sinus.

5^th  group – patients with OMS caused by perforation or fistula in the sinus.

6^th group – patients with OMS the cause of which is not identified.

The research of every clinical group involved histological investigation of biopsy samples in 20 patients.

The microscopic investigation of the first group showed that in some cases mucous membrane of maxillary sinus is covered by multirowed ciliated epithelium. At the same time there are also observations of evident proliferation of surface epithelium cells.

Maxillary sinus is formed with an immature granulous tissue which consists of a large number of vessels. Their walls have homogenous structure and are stained red by van Gieson’s stain. Sometimes the walls of vessels resemble fibrous formations. The vessels are located between numerous thin fibers of connective tissue and are stained delicate carnation by van Gieson’s stain, collagen fibers are blue and few elastic fibers are red by Mallory’s stain (pic. 1). 

There are a lot of cells around the vessels, they mostly include lymphocytes, plasmocytes, small and middle-sized fibroblasts.

There are far less middle-sized fibroblasts and they are spindle-shaped with a light oval nucleus consisting of 1-2 nucleoli. It is necessary to admit that the peak concentration of fibroblasts is recorded in the areas of tender connective tissue where there is the peak concentration of sulphated glycosaminoglycans which occur by diffuse staining bluish under effect of toluidine blue.

Table 1

Intensity of histochemical reactions of glycosaminoglycans identification in fibroblasts in arbitrary units of optical density in the 1st group.

Р< 0,05 comparing with non-sulphated glycosaminoglycans.

Among the fibers of connective tissue there are prolate fibrocytes, their nucleus contains solid heterochromatin which is intensely stained with hematoxylin by hematoxylin and eosin staining. It is possible to see an irregularly marked swelling.

The second investigation group includes two variants of maxillary sinusitis course. The part of biopsy samples of this group against the background of sclerotic changes in the sinus show accumulations of exudate consisting mostly of polynuclear leukocytes and pyocytes which completely fill the cavity and characterize purulent inflammation. Almost all vessels per field of vision are dilated and parietally filled with leukocytes. There is diffuse staining blue which emphasizes the presence of fibrin in exudate by Mallory’s staining (pic. 2).

Sclerotic changes found in the sinus cavity are confirmed by van Gieson’s staining by which the fibers of connective tissue are stained red.

Along with the abovementioned changes there are cases when the sinus cavity is filled with immature granule tissue together with the occurrence of papillary formations the surface of which is lined with multirowed epithelium that is the proliferation of surface epithelium is expressed. Some biopsy samples are characterized by damage of staratification of epithelium basal layers and occurance of cells with hyperchromatic nuclei intensely stained blue with hematoxylin.

Basal sections of epithelial layer consist of non-sulphated glycosaminoglycans which is confirmed by diffuse staining bluish by affecting the samples with toluidine blue (pic. 3). While affecting the sections by hyaluronidase they become lighter that emphasizes the accuracy of performed reaction to glycosaminoglycans. Optical density of non-sulphated glycosaminoglycans and consequently the reaction intensity are expressed more than by the identification of sulphated glycosaminoglycans (table 2).

Table 2

Intensity of histochemical reactions of glycosaminoglycans identification in basal layers of surface epithelium in arbitrary units of optical density in the 2^nd group.

Р< 0,05 comparing with sulphated glycosaminoglycans 

            The investigation of biopsy samples of the third group showed glandular polyps in maxillary sinuses, the former consist of a great amount of newly formed glands. The glands are oval and slightly ovoid and they are located in the full thickness of polyp sometimes forming a complete glandular space.

         Glands are mostly lined with prolate epithelial cells which consist of light nuclei with nucleoli and are moderately hematoxylin’s stained bluish by hematoxylin and eosin staining. Many glands are characterized by combination of epithelial cells proliferation with dystrophic changes of their cytoplasm by means of tiny oval vacuoles occurence (pic. 4), which may be a sign of apoptosis.

There are also few glands with cystic dilatation of their cavity and moderate flattening of lining epithelium. Basal sections in the thickness of gland’s membrane contain connective-tissue fibers intensely stained red by van Gieson’s staining that characterize the onset of sclerotic changes in them. As in the previous group (2) basal sections of epithelial layer consist of non-sulphated glycosaminoglycans which is confirmed by diffuse staining bluish while treatment of samples with toluidine blue, after effecting the sections by hyaluronidase they become lighter that emphasizes the accuracy of performed reaction to glycosaminoglycans. Optical density and consequently the reaction intensity to non-sulphated glycosaminoglycans increase comparing with optical density of sulphated glycosaminoglycans (table 3).

Table 3

Intensity of histochemical reactions of glycosaminoglycans identification in basal layers of surface epithelium in arbitrary units of optical density in the 3d group.

Р< 0,05 comparing with sulphated glycosaminoglycans.

It is necessary to pay attention to proliferation of the most part of columnar epithelium which covers the surface of papillary formations of polyps. It is possible to see stratified epithelium with abrupt hyperplasia of basal cells which become prolate with the occurrence of mitosis in some of the cells. The number of papillary formations ranges from 1-2 to 4-5. Subepithelially connective-tissue part of papillae is represented by the cells of connective-tissue row that is mature fibroblasts where large fibroblasts mostly dominate smaller ones. There are much less middle-sized fibroblasts and they are spindle-shaped with a light oval nucleus consisting of 1-2 nucleoli. It is necessary to admit that there is the same principle in these biopsy samples when the peak concentration of fibroblasts is recorded in the areas of connective tissue rich with sulphated glycosaminoglycans which occur by diffuse staining bluish under effect of toluidine blue, after affecting the sections by hyaluronidase they become lighter. Optical density of sulphated glycosaminoglycans and consequently the reaction intensity exceed the last one while identifying non-sulphated glycosaminoglycans (table 4).

                                                                                                                 Table 4

Intensity of histochemical reactions of glycosaminoglycans identification in fibroblasts in arbitrary units of optical density in the 3d group.

Р< 0,05 comparing with non-sulphated glycosaminoglycans.

Ciliary cells characteristic for epithelial layer are few. Their nuclei are close to ovoid shape and are almost located on the basal membrane.

There are biopsy samples where sinuses are filled by mostly deep fibrous connective tissue intensely stained red by van Gieson’s staining.

The investigation of the fourth group showed that biopsy samples of maxillary sinuses mostly contain vascular polyps which are characterised by a big number of thinwalled vessels mostly of capillaceous type without endothelium proliferation (pic. 5). The lumens of such vessels are dilated and partly filled with erythrocytes. There are areolar tissues intensely stained red by van Gieson’s staining around the vessels. There are sleeves of tender connective tissue around separate vessels.

There are fibrocytes and fibroblasts around the fibers of connective tissue. Sometimes it is possible to see plasmocytes and plasmoblasts and also lymphocytes. By Mallory’s staining bluish staining is more visible across dilated, partly plethoric vessels. Red elastic fibers by Mallory’s stain can be found in the walls of singular vessels.

In the areas of polyps’ connective tissue where there are fibroblasts it was possible to notice moderate concentration of sulphated glycosaminoglycans stained blue with the same optic density (table 5). Consequently the optic density of sections staining to non-sulphated glycosaminoglycans is decreased.

Table 5

Intensity of histochemical reactions of glycosaminoglycans identification in connective tissue in arbitrary units of optical density in the 4th group.

Р< 0,05 comparing with non-sulphated glycosaminoglycans.

         The histological investigation of biopsy samples of maxillary sinus in patients of the fifth group showed that there are mostly glandular polyps with proliferation of surface and glandular epithelium.

         Glandular polyps are characterised by the presence of papillary formations which contain glands. Glandular formations are mostly oval-shaped, multirowed epithelium in them is characterised by hyperplasia of prolate basal cells with the presence of mitosis in the cells. The number of glands in biopsy samples under analysis is not high, it ranges from 2 to 5. Glands are located in sufficiently thick stroma which is presented by deep fibrous connective tissue which is stained intensive red by van Gieson’s staining. It is necessary to admit that these biosy samples have a weak reaction to sulphated glycosaminoglycans, more expressed reaction is to non-sulphated glycosaminoglycans (table 6).

Table 6

Intensity of histochemical reactions of glycosaminoglycans identification in connective tissue in arbitrary units of optical density in the 5th group.

Р< 0,05 comparing with non-sulphated glycosaminoglycans.

         There are such polyps which are close to epidermoid ones with well expressed stroma according to their histological structure.

         Some clinical observations of this group showed the diagnosis of inverted papilloma with sufficiently thick, sclerotic papilloma (p

Such papilloma is covered with columnar epithelium. Epithelium with dystrophic changes in cytoplasm represented as local vacuolization of cytoplasm.

The investigation of the sixth group showed simple polyps in the maxillary sinus almost in all observations. The surface of a simple polyp in some cases is covered by columnar epithelium and in other cases by multirowed epithelium. Cell cytoplasm of surface epithelium is eosinophilic and contains tiny single vacuoles. Nuclei are intensely stained by hematoxylin and located in parallel with a basal membrane in the form of beads. At the same time there are tiny papillary formations on the surface of a polyp where nuclei are located at different levels in the form of double-circuit picture. Under surface epithelium there are few, small glands which are lined by light cells of glandular epithelium with unequal apical edges. Polyp’s stroma is areolar, it is represented by the fibers of connective tissue stained red by van Gieson’s staining and few lymphocytes, plasma cells and fibroblasts (pic. 7).

 Analyzing the received histological data it is necessary to admit that all investigated groups with odontogenic maxillary sinusitis are characterized by chronic inflammatory process. The latter is associated with and results in occurrence of hyperplasic processes in sinuses in the form of polyps and even papillomas.

Different stages of respiratory epithelium transformation are many times described at the time of inflammatory and regenerative processes in sinuses. As it is known these processes occur not without participation of fibroblasts and collagen fibrils. It is a difficult and expansive process. Forming and course of regenerative processes at the time of inflammatory reactions in many ways depend on the state of fibroblasts and connective tissue. A  ground substance of connective tissue contains sulphated glycosaminoglycans which determine the strength of cell membranes, favor regenerative processes, lower tissue porosity and decrease hydrophilia of tissues and non-sulphated glycosaminoglycans on the contrary favor the increase of tissues hydrophilia and increase the porosity of cell membranes that restrains a reparative process from one side and from another side low activity of fibroblasts results in recession of stroma development and by this increases the proliferation risk of parenchyma in the presence of different chronically running processes.

Because of this besides common traditional histological staining techniques we used the Romhangi method (1963) which allowed identifying the level of maturity of connective tissue and fibroblasts for determination of peculiarities in reparative process and its prediction as only qualitative cellular composition at the time of inflammation and reparation results in benign outcome of pathological processes.

Analyzing the first group of clinical observations it is necessary to admit that the diagnosed histological changes indicate the formation of granulation tissue after past acute maxillary sinusitis with the elements of process chronization. The duration of process course is confirmed by the presence of connective tissue, changes of vessels walls with the occurrence of sclerosis signs in them, that is recorded by the used techniques of staining of specimen in this group. High reaction intensity by identification of sulphated glycosaminoglycans may predict a benign outcome of the process.

The second group of clinical observations after chronical inflammation of mucous membrane is diagnosed with acute purulent inflammation with expressed hyperplastic changes of surface epithelium with local damage of layer stratification of multirowed epithelium. It is naturally that this group is characterized by decrease of reaction intensity to sulphated glycosaminoglycans and intensity increase to non-sulphated glycosaminoglycans.

Clinical observations of 3-6 groups are almost in all cases characterized by the diagnosis of hyperplastic processes in the form of occurrence of simple (6^th group), vascular (4^th group), transitional cell (3d, 4^th groups) polyps, and in the 5^th group the presence of papilloma. Moreover the given pathology occurs in association with expressed chronic inflammatory processes in the sinus and against their background. The abovementioned is consequently associated with the occurrence of dysplastic processes in surface and glandular epithelium of polyps. In parallel there is the intensity increase of histochemical reaction to non-sulphated glycosaminoglycans that is shown in the given investigation.

The occurrence of transitional cell papilloma which is diagnosed in the 5^th group is likely to be explained as the increase of dysregenerative processes by chronically proceeding inflammation in maxillary sinus.

Conclusion: Thus, continually existing inflammatory processes in sinuses may cause the occurrence of hard hyperplastic processes in them up to development of tumors and generalization of infectious process not only within the sinuses but body as a whole.

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