Endoscopic treatment of sinonasal disease in patients who have had orthognathic surgery

Morphological changes in the inferior nasal passage associated with superior repositioning of the maxilla with/without horseshoe osteotomy or turbinectomy

Superior repositioning of the maxilla during Le Fort I osteotomy (LFI) may narrow the inferior nasal passage. This retrospective study was performed to investigate morphological changes in the inferior nasal passage following LFI with/without additional procedures performed for nasal ventilation (horseshoe osteotomy or inferior turbinate partial resection). Three groups of patients were compared: those undergoing conventional LFI (Conv, 63 patients), LFI with horseshoe osteotomy (Hs, eight patients), and LFI with inferior turbinate partial resection (Turb, 21 patients). Coronal computed tomography images were used to evaluate the degree of stenosis of the inferior nasal passage. The soft tissue and bony tissue volumes in the inferior turbinate were also calculated three-dimensionally. The rate of obstruction of the inferior nasal passage postoperative was 65.9%, 50%, and 11.9% in the Conv, Hs, and Turb groups, respectively (Fisher's exact test, P < 0.001). Patients in the Turb group had significantly less nasal obstruction regardless of the pitch direction of the maxillary movement or volume of the bone in the inferior turbinate (all P < 0.001). In conclusion, for patients with high superior repositioning and well-developed bony tissue in the inferior turbinate, additional procedures are recommended to maintain the ventilation of the nasal passage postoperatively.

Changes in Maxillary Sinus Volume and Mucosal Thickness Post Bimaxillary Advancement Procedures: A Retrospective Study

Background: Bimaxillary surgery is an elemental procedure in the field of cranio-maxillofacial surgery. It allows for the correction of even the most challenging cases of maxillomandibular disorders, malocclusion, facial asymmetry, and disproportion. The osteotomies and maneuvers carried out during the procedure result in changes to the surrounding tissues, including the maxillary sinuses (MS). The aim of this study was to assess the change in the maxillary sinus volume and the thickness of the mucosa after maxillomandibular advancement (MMA) surgeries. Methods: A group of 25 patients who underwent MMA surgery were included in the study. Computed tomography (CT) of the head and neck region was performed 2 weeks preoperatively and 6 months postoperatively. Acquired Digital Imaging and Communications in Medicine (DICOM) files were analyzed using different software programs to calculate the medium MS mucosa thickness and MS volume. Results: A statistically significant reduction in MS volume was observed (p = 0.015). The change in the median thickness of the MS mucosa was not statistically significant. The median sella-nasion-A point angle (SNA angle) value of the group increased from 80.2 to 83.4 degrees. A weak negative correlation between the SNA delta and the MS volume delta was observed. Spearman's rank coefficient: (ρ s = -0.381, p = 0.060). Conclusions: The MMA surgery results in a reduction in the MS volume. The amount of forward movement of the maxilla may be correlated with the extent of the MS volume reduction.

Detection of multidrug-resistant bacteria in the nasal cavities and evaluation of sinus disorders in patients undergoing Le Fort I osteotomy

INTRODUCTION

Orthognathic surgery can lead to sinus alterations, including sinusitis, attributed to the exposure of maxillary sinuses during Le Fort I osteotomy. Furthermore, being a hospital-based procedure, there is potential risk of complications arising from bacteria prevalent in such environments. This study evaluated maxillary sinusitis occurrence and the presence of multidrug-resistant bacteria in the nasal cavity before and after orthognathic surgery.

METHODS

Ten patients with dentofacial deformities underwent Le Fort I osteotomy. Clinical evaluations using SNOT-22 questionnaire were performed, and nasal cavity samples were collected pre-surgery and 3-6 months post-surgery to quantify total mesophilic bacteria and detect Staphylococcus aureus, Acinetobacter baumannii, and Klebsiella pneumoniae. Cone Beam Computed Tomography (CBCT) was performed pre- and post-operatively, and the results were evaluated using the Lund-Mackay system. This study was registered and approved by the Research Ethics Committee of PUCRS (No. 4.683.066).

RESULTS

The evaluation of SNOT-22 revealed that five patients showed an improvement in symptoms, while two remained in the same range of interpretation. One patient developed post-operative maxillary sinusitis, which was not detected at the time of evaluation by SNOT-22 or CBCT. CBCT showed a worsening sinus condition in three patients, two of whom had a significant increase in total bacteria count in their nasal cavities. The Brodsky scale was used to assess hypertrophy in palatine tonsils, where 60% of the subjects had grade 1 tonsils, 20% had grade 2 and 20% had grade 3. None of the patients had grade 4 tonsils, which would indicate more than 75% obstruction. Two patients harboured S. aureus and K. pneumoniae in their nasal cavities. Notably, K. pneumoniae, which was multidrug-resistant, was present in the nasal cavity of patients even before surgery, but this did not result in maxillary sinusitis, likely due to the patients' young and healthy condition.

CONCLUSION

There was an improvement in signs and symptoms of maxillary sinusitis and quality of life in most patients after orthognathic surgery. However, some patients may still harbour multidrug-resistant bacteria, even if they are asymptomatic. Therefore, a thorough pre-operative assessment is essential to avoid difficult-to-treat post-operative complications.

Assessment of Maxillary Sinus Variations Post-LeFort: A Systematic Review

Background

The purpose of this article was to systematically review maxillary sinus changes after LeFort. We examined and analyzed the anatomical abnormalities that occurred following LeFort I osteotomy, as well as the abnormalities of maxillary sinus volume (MSV) before and after the operation.

Methods

A systematic search was conducted on various databases, such as Google Scholar, PubMed, and Scopus. The articles used were in English and original. This study was conducted until September 2023, and after reviewing the articles, several keywords, such as "Maxillary sinus" and "LeFort I osteotomy", were employed. The obtained data were evaluated based on the PICO framework.

Results

Findings from 15 studies showed that the amount of MSV decreased before and after the operation (considering the three dimensions of the sinus, the measurement was performed linearly). These reduction values differed between men and women, with men having a greater reduction. As is the case with other operations, there were some side effects associated with this type of operation that some patients experienced postoperatively.

Conclusion

In both male and female patients, the MSV was reduced after one-piece and multi-segment osteotomies. Nonetheless, one-piece LeFort I osteotomy showed a higher reduction in MSV than the multi-segment osteotomy method, according to this systematic review and meta-analysis.

Nasal Airway Function After Prophylactic Intranasal Surgery for Excessive Maxillary Superior Repositioning: A Retrospective Cohort Study Using the Nasal Obstruction Symptom Evaluation Scale

PURPOSE

The purpose of this study is to evaluate the degree of nasal airway function after simultaneous intranasal corrective surgery and bimaxillary surgery in patients with excessive superior maxillary repositioning.

MATERIALS AND METHODS

A retrospective cohort study was conducted on consecutive LeFort I superior repositioning patients who also underwent simultaneous intranasal surgery to prevent airway obstruction between 2015 and 2019. The Nasal Obstruction Symptom Evaluation (NOSE) scale was administered to all participants before the operation and after 1 year.

RESULTS

Fifteen patients (n=12 females; n=3 males) among 440 bimaxillary orthognathic surgery patients were enrolled with inclusion criteria of maxillary impaction between 8 and 12 mm. All subjects underwent at least LeFort I osteotomy, septoplasty, bilateral inferior turbinectomy, and bilateral sagittal split osteotomy. Two patients received custom-made total joint prosthesis. The primary outcome variable investigated was nasal function. The mean preop Nasal Obstruction Symptom Evaluation score was 24.33 and the mean postop score was 5.

CONCLUSIONS

Intranasal procedures performed simultaneously with 8 mm or more maxillary impaction improves postoperative functional outcome in terms of nasal airway patency and breathing. Partial inferior turbinectomies and septoplasty should be performed consistently to avoid nasal obstruction if the impaction of upper jaw exceeds 8 mm.

Evaluation of Related Factors of Maxillary Sinusitis After Le Fort I Osteotomy Based on Computed Tomography: A Retrospective Case-Control Study

ABSTRACT

Maxillary sinusitis is 1 of the postoperative complications of the Le Fort I osteotomy, this study investigated the related factors of maxillary sinusitis after Le Fort I osteotomy. A total of 23 cases, 92 controls, and 11 related factors were included in this case-control study with a 1:4 case-control ratio. The risk factors for maxillary sinusitis after Le Fort I were examined by least absolute shrinkage and selection operator multivariate conditional logistic regression and least absolute shrinkage and selection operator multivariate linear regression. The patency of maxillary sinus ostium at 6 months after surgery was significantly associated with maxillary sinusitis after Le Fort I osteotomy. Compared with the obstructed maxillary sinus ostium, the percentage of the volume of the healthy air cavity in the complete sinus cavity increased 70.7% when the maxillary sinus ostium was unobstructed, and 95% confidence interval was 0.610 to 0.805. Similarly, when the maxillary sinus ostium was wide, the percentage increased 6.0% compared with the narrow 1, and 95% confidence interval was 0.013 to 0.107. This study indicated that the patency of maxillary sinus ostium has an important impact on maxillary sinusitis after Le Fort I osteotomy. Close attention should be paid to maintain the maxillary sinus ostium and the drainage of maxillary sinuses unobstructed in a clinical setting.

Nasal Obstruction Evaluation After LeFort I Osteotomy: A Pilot Study

ABSTRACT

Previous literature has documented changes in nasal obstruction after acute LeFort I osteotomy. However, there is a paucity of studies that evaluate distraction-mediated LeFort I (DO-LFI) without concomitant intranasal interventions using the nasal obstruction symptom evaluation (NOSE) scale in Class III patients. The purpose of this study is to objectively evaluate nasal obstruction quality of life through the NOSE scale in patients undergoing DO-LFI. Inclusion into the study required both a preoperative (1 year ≤ date of service) and postoperative (≥6 months and ≤2 years) NOSE scale administration. Nasal obstruction symptom evaluation scales were compared using Wilcoxon signed rank test. There was a significant difference in composite NOSE scales, x̃ = 8.0 (interquartile range: 4.0-11.0), x̃ = 1.0 (interquartile range: 1.0-3.0), P < 0.017, preoperatively and postoperatively respectfully. Additionally, when looking at individual components of the NOSE scale, nasal congestion or stuffiness, and trouble breathing through nose were significantly improved after DO-LFI (P < 0.017). Nasal blockage or obstruction (P > 0.084) and trouble breathing when exercising (P > 0.076) trended towards significant improvement, as well. Trouble sleeping did not differ, P > 0.611. We elucidate, in this pilot study, that there is an association between DO-LFI and patient reported nasal obstructive symptoms. Future prospective studies utilizing the NOSE scale are needed to determine causality.

Effect of maxillary surgical movement on nasal cavity and maxillary sinus dimensions and function after Le Fort I osteotomy

This study was designed to evaluate the effects of different maxillary movements performed in Le Fort I surgery on the anatomy of the nasal cavity and maxillary sinus, occurrence of rhinosinusitis, and nasal airflow. Patients were divided into three groups: group I underwent pure advancement, group II underwent advancement with yaw rotation, and group III underwent advancement with impaction movements. All evaluations were performed using pre- and postoperative computed tomography images and surveys. Twenty-eight patients were enrolled. The mean pre- and postoperative nasal air volumes in group I were 22.74 ± 6.32 cm³ and 25.17 ± 6.19 cm³, respectively, showing a significant increase (P = 0.041). The mean pre- and postoperative maxillary sinus air volumes were 33.94 ± 13.72 cm³ and 26.28 ± 14.12 cm³ in group II and 35.29 ± 9.58 cm³ and 28.65 ± 8.42 cm³ in group III, respectively, showing significant reductions (P = 0.028 and P = 0.007, respectively). For all movements, the occurrence of septum deviation and nasal airflow impairment was not statistically significant. Pure maxillary advancement movement enhanced nasal cavity air volume. The yaw rotation movement significantly increased quantitative clinical rhinosinusitis symptoms. The risk of airflow impairment following Le Fort I surgery is low.

Maxillary sinus recovery after LeFort I osteotomy: a prospective clinical and radiographic evaluation

Introduction: The purpose of this study was to obtain insight into the perioperative condition of the maxillary sinus in the LeFort I osteotomy by evaluating clinically and radiographically. Materials and methods: 25 patients who required conventional LeFort I procedures for orthognathic correction were included in the study. Damage to the maxillary sinus during the procedure and its recovery were prospectively analysed using validated questionnaires for sino-nasal complaints using RSOM-31 (RSOM − rhinosinusitis outcome measure), VAS score (VAS − visual analogue scale) and CT scan to compare and analyse changes in maxillary sinus prior to surgery and postoperatively 2 months after the surgery. The scores obtained from RSOM-31 questionnaire was analysed using Chi-square test, VAS questionnaire was interpreted using Wilcoxon sign rank test and CT scan findings were analysed using Fischer's exact test. Results: Mucosal thickening assessed using CT scan was the only consistent finding that was evident for all the patients who underwent LeFort I osteotomy which showed a statistically significant results of P < 0.05, whereas clinical correlation showed insignificant results of P > 0.05. Conclusion: In our attempt on extensive patient analysis we found that mucosal thickening was the prime alteration that was observed radiographically and no clinical changes were evident.

Evaluation of Sinonasal Change After Lefort I Osteotomy Using Cone Beam Computed Tomography Images

Orthognathic surgery including Le Fort I osteotomy involves changes in the nasal septum and maxillary sinus. This study assesses nasal septum changes after Le Fort I osteotomy using cone beam computed tomography images and evaluates mucosal changes in the maxillary sinus after the surgery.This was a retrospective study of 33 patients who underwent orthognathic surgery including Le Fort I osteotomy. To assess the maxillary sinus, changes in the mucosa of the maxillary sinus were analyzed by volume and geometry. We measured the air cavity per se and mucosal thickening of the maxillary sinus using SIMPLANT (Materialise, Belgium) software. And the geometry of the distribution of the mucosa was analyzed using cone beam computed tomography images.The septal angle was decreased after surgery, but not significantly (P > 0.05). The volume reduction of the air cavity per se and the volume increase associated with mucosal thickening were statistically significant (P < 0.05). Mucosal thickening was observed in the posterior-inferior direction.In this study, nasal septum deviation was not statistically significant after Le Fort I osteotomy. Decrease of the air cavity per se, decrease of the total volume of the maxillary sinus, and increase of mucosal thickening were prominent. Furthermore, the mucosal thickening that occurs after surgery appears to be mainly in the posterior lower part of the maxillary sinus.

Correction of Symptomatic Chronic Nasal Airway Obstruction in Conjunction With Bimaxillary Orthognathic Surgery: Does It Complicate Recovery and Is It Effective?

PURPOSE

The purpose of this study was to assess the safety and efficacy of intranasal procedures carried out simultaneously with bimaxillary orthognathic surgery.

MATERIALS AND METHODS

The authors executed a retrospective cohort study derived from patients treated by a single surgeon at 1 institution from 2004 through 2013 with a minimum follow-up of 1 year (range, 1 to 10 yr). An index study group consisting of a consecutive series of patients with symptomatic chronic obstructive nasal breathing (CONB) and a bimaxillary developmental dentofacial deformity (DFD) also involving the chin were identified. They underwent a minimum of: Le Fort I osteotomy, bilateral sagittal ramus osteotomies, septoplasty, inferior turbinate reduction (ITR), and osseous genioplasty. Study variables included age at operation, gender, pattern of presenting DFD, presence of obstructive sleep apnea, segmentation of the maxilla, and airway management. The primary outcome variable studied was residual CONB.

RESULTS

During the study period, 262 patients met the inclusion criteria. Their age at operation averaged 25 years (range, 13 to 63 yr) and 134 were female (51%). The major patterns of presenting DFD included long face (29%) and maxillary deficiency (25%). No patients required nasal packing, reintubation, tracheostomy, or blood transfusion. In 6 of the 262 patients (2%), the intranasal procedures did not resolve nasal breathing difficulties. In these patients, procedures recommended included synechiae release (n = 3), revision septoplasty (n = 3), and further ITR (n = 4). An association between age at time of surgery and non-segmental Le Fort I osteotomy with the occurrence of residual nasal obstruction was confirmed.

CONCLUSIONS

When completing septoplasty and ITR through a Le Fort I, airway management need not be altered from standard protocol. The management of CONB in conjunction with orthognathic surgery is highly effective, with few complications. Non-segmental Le Fort I in patients at least 40 years of age is more likely to be associated with residual CONB, but the incidence remains low.

Is Le Fort I Osteotomy Associated With Maxillary Sinusitis?

PURPOSE

The purpose of the present study was to investigate the association between Le Fort I osteotomy and the anatomic, radiologic, and symptomatic modifications of the maxillary sinus.

MATERIALS AND METHODS

Subjects who had undergone Le Fort I osteotomy from January 2008 to December 2013 were enrolled in a retrospective cohort study. The eligibility criteria were the availability of a cone beam computed tomography (CBCT) scan taken before and 12 to 24 months after the procedure. The exclusion criteria were the unavailability of CBCT scans, the use of tobacco, and previous orthognathic procedures. The primary predictor variable was time (pre-vs postoperative). The primary outcome variables were the sinus volume, mucosal thickening, iatrogenic alterations in the sinus anatomy, and rhinosinusitis symptoms, evaluated using the Sino-Nasal Outcome 20-item Test (SNOT-20). Descriptive statistics were computed for each variable, and paired analyses were used to compare the pre- and postoperative values.

RESULTS

The data from 64 subjects (mean age 27; 59.4% were female; median follow-up 32.4 months, range 13 to 66 months) were studied. Postoperatively, 1.6% of the sample (0% preoperatively) had moderate-to-severe and 15.6% (3.1% preoperatively) had mild-to-moderate sinusitis symptoms. The rest of the sample presented with mild to no symptoms. The increase in the SNOT scores after surgery was statistically significant (P = .016). Radiologic evidence of postoperative inflammatory processes affecting the paranasal sinuses was found in 27.3% of the sinuses (9.4% preoperatively). The postoperative Lund-Mackay scores were significantly greater (P = .0005). A 19% decrease was found in the mean postoperative sinus volume, with a 37% incidence of iatrogenic injury.

CONCLUSIONS

The study results indicate that Le Fort I osteotomies can have an important impact on sinus health. The postoperative radiologic evidence of maxillary sinus inflammatory processes and the incidence of rhinosinusitis symptoms and iatrogenic damage in these patients have led us to conclude that CBCT scans and the SNOT-20 questionnaire should be used routinely during postoperative monitoring. Larger long-term studies are warranted to clarify the postoperative outcomes and complications.

Fibroscopic findings in patients following maxillary osteotomies in orthognathic surgery

OBJECTIVE

To evaluate the intranasal complications in patients submitted to maxillary Le Fort osteotomy within the orthognathic evaluation through flexible fibroscope, method which is safety, reliable and minimally invasive.

MATERIALS AND METHODS

A prospective, systematic non-randomized study is presented with a series of 47 patients who underwent a Le Fort I maxillary osteotomy due to dentofacial deformity between January 2008 and December 2008. The patients who were included underwent an evaluation of nasal respiratory function using a questionnaire designed for this objective, after which a fibroscopic examination was carried out.

RESULTS

With regards to the results of the NOSE questionnaire, 4/47 patients had Grade 2 nasal obstruction before the surgery. After the intervention, three improved to a 0-1 grade. 3/47 patients reported snoring during sleep without OSAS that was not modified as a result of the surgery. 2/47 patients presented with sequelae regarding the deviation of the septum, and 1/47 had a luxation of the anterior nasal spine that had not been recorded before the orthognathic surgery. The presence of synechiae was observed in 3/47 cases. A septal perforated mucosa was found in the IV area of the nasal septum. Hypertrophy of the lower turbinate was observed in 4/47 cases.

CONCLUSION

The fibroscope procedure is minimally invasive and it does not require local anesthesia or sedation, and it allows the surgeon to carry out an immediate and exhaustive evaluation, on an outpatient basis, of possible septal and nasal sequelae in patients undergoing orthognathic surgery.

Consequences and management of nasal airway obstruction in the dentofacial deformity patient

INTRODUCTION

At the time of orthognathic surgery the maxillofacial surgeon has an opportunity to further contribute to a patient's quality of life by simultaneously addressing long-standing breathing and sinus drainage difficulties that may coexist with the jaw deformity. Breathing difficulties may range from isolated symptomatic nasal airway obstruction to obstructive sleep apnea syndrome and should not be overlooked. The impact of the combined occurrence of nasal obstruction and maxillary deformity has been recognized and discussed in the literature.

RECENT FINDINGS

Studies have established the correlation of obstructed nasal breathing with the development and predilection for specific patterns of dentofacial deformities. It is imperative that the evaluation of either obstructed nasal breathing or a presenting dentofacial deformity take into account both aspects. Treatment of maxillary dysplasia with specific emphasis of transverse expansion and correction of other intranasal sites of obstruction including deviated septum and hypertrophied inferior turbinates seeks to simultaneously address chronic difficulties with nasal breathing, sinus drainage and the presenting jaw deformity.

SUMMARY

A long-standing forced mouth breathing pattern with open mouth posture is known to impact on maxillo-mandibular growth and be a major contributing factor to developmental jaw deformities. When indicated, simultaneous management of the maxillary jaw deformity (Le Fort I osteotomy) and intranasal abnormality (septoplasty, reduction of inferior turbinates, recontouring of nasal apertures) is effective for the symptomatic relief of nasal airway obstruction. The complication rate for the intranasal procedures and Le Fort I osteotomy when completed simultaneously are minimal and not higher than expected when each procedure is carried out as an isolated event.

Simultaneous functional endoscopic sinus surgery and esthetic rhinoplasty in orthognathic patients

PURPOSE

Patients treated for dentofacial deformities may be predisposed to aggravated sinonasal disease postoperatively, particularly if concurrent rhinoplasty is performed. The authors present their experience with simultaneous rhinoplasty, maxillary/mandibular osteotomies, and functional endoscopic sinus surgery (FESS).

PATIENTS AND METHODS

Thirteen patients were treated with simultaneous rhinoplasty, maxillary/mandibular osteotomies, and FESS from January 2002 to December 2005. An operative algorithm for patients with dentofacial deformities requiring rhinoplasty was developed. The surgical procedure was performed under general anesthesia with nasotracheal intubation and maxillary/mandibular osteotomies first. Nasotracheal intubation was then converted to orotracheal intubation and FESS was performed. The third step was correction of the esthetic deformities of the nose through an open approach.

RESULTS

In all cases, it was possible to successfully complete the combined operation. Median operation time was: 2 hours and 18 minutes for orthognathic bimaxillary surgery, 54 minutes for rhinoplastic surgery; and 23 minutes for FESS. All the patients had good esthetic and functional results and were free from symptoms consistent with previous rhinosinusitis.

CONCLUSION

The combination of orthognathic surgery, rhinoplasty, and FESS in selected cases is safe and effective.

Simultaneous intranasal procedures to improve chronic obstructive nasal breathing in patients undergoing maxillary (le fort I) osteotomy

PURPOSE

The aim of this study was to evaluate the safety and efficacy of septoplasty and inferior turbinate reduction, carried out through a Le Fort I osteotomy as part of the correction of a dentofacial deformity, designed to improve nasal breathing in patients who reported pre-existing nasal airway obstruction and had documented septal deviation and inferior turbinate hypertrophy.

PATIENTS AND METHODS

A validated outcomes instrument, the Nasal Obstruction Symptom Evaluation (NOSE) questionnaire, was used to objectively assess the extent of clinical nasal obstruction both before and after septoplasty and inferior turbinate reduction performed at the time of Le Fort I down-fracture. The study group comprised 43 consecutive patients scheduled for orthognathic surgery (including Le Fort I osteotomy) over a 12-month period who complained of chronic nasal obstruction and were found (by an independent otolaryngology evaluation) to have septal deviation and inferior turbinate hypertrophy unresponsive to medical therapy, who met the inclusion criteria, and who agreed to the procedures (septoplasty and turbinate reduction). The data collected included age, gender, health and social history, type of dentofacial deformity, concomitant surgical procedures, and any associated postoperative complications.

RESULTS

For the 43 study patients, significant improvement in nasal breathing was documented (by NOSE scores) at 3 months (P < .001) after the procedures (Le Fort I osteotomy, septoplasty, and inferior turbinate reduction). Comparison of the 3-month and 6-month NOSE scores showed maintenance of improved nasal breathing with further improvement that did not demonstrate statistical significance.

CONCLUSIONS

The findings of this study indicate that simultaneous management of the maxillary jaw deformity (Le Fort I osteotomy) and intranasal pathology (septoplasty and reduction of inferior turbinates) were effective for the symptomatic relief of nasal airway obstruction. The complication rate for the intranasal procedures completed simultaneously with a Le Fort I osteotomy was minimal and not dissimilar to the rates reported for each procedure performed as an isolated event.