Epistaxis After Orthognathic Surgery: Literature Review and Three Case Studies

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.

Postoperative hemorrhage after Le Fort I osteotomy hemostasis with angiographic embolization: report of two cases

This study reported two cases of acute life-threatening hemorrhage after Le Fort I osteotomy. In both cases, computed tomography and angiography revealed damage to the descending palatine artery, which was successfully treated by angiographic embolization. Although massive hemorrhage after Le Fort I osteotomy is rare, acute hemorrhage from the postoperative area may occur. Angiographic embolization is useful in cases of such hemorrhage from the posterior nasal cavity where endoscopic hemostasis is not possible.

A rare complication of hemolacria after Le fort I osteotomy: a case presentation

Background

Nasolacrimal duct obstruction (NDO) is a common pathology preventing the proper drainage of the tears, and its main symptom is epiphora. Secondary acquired nasolacrimal duct obstruction (SANDO) can be due to a variety of causes including infection, trauma, or neoplasms. It has been reported to occur with different forms of maxillofacial trauma, especially Le Fort II, Le Fort III, naso-orbital-ethmoidal, and orbital floor fractures.

Case presentation

A 20-year-old Egyptian female presented to correct a facial disharmony due to a cleft lip and palate defect. The patient reported a history of congenital NDO and had deficient lateral nasal walls. Bimaxillary surgery was planned, including a Le Fort I osteotomy for the maxilla and bilateral sagittal split osteotomy for the mandible. The surgery was uneventful, but the patient complained from bloody tears or hemolacria few days postoperatively. This complication began to cease spontaneously after 2 days and completely recovered after 4 days.

Conclusion

Hemolacria is an infrequent finding after maxillofacial surgeries and may be associated with CLP surgeries more than other surgeries. In this case, it was easily managed, and surgeons should be more aware of it to try to prevent its occurrence.