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Endoscopic treatment of sinonasal disease in patients who have had orthognathic surgery
British Journal of Oral and Maxillofacial Surgery (2000) 38, 177–184 © 2000 The British Association of Oral and Maxillofacial Surgeons doi:10.1054/bjom.1999.0195
BRITISH JOURNAL OF ORAL
& M A X I L L O FA C I A L S U R G E RY
Endoscopic treatment of sinonasal disease in patients who have had orthognathic surgery J. J. Moses, C. R. Lange,* A. Arredondo† Medical Director; †Post-Doctoral Fellow, Pacific Clinical Research Foundation, Encinitas, CA, USA; *Resident Physician, Department of Maxillofacial Plastic Surgery, University of Lubeck, Lubeck, Germany SUMMARY. Certain skeletofacial patterns may be predisposed to aggravated sinonasal disease postoperatively. These may include, but are not limited to, facial skeletal asymmetries with high septal deviations and those with obstructive nasal respiration and mouth breathing that leads to skeletal growth disturbances such as vertical maxillary hyperplasia and apertognathism. These sinonasal diseases may partly be the result of osteomeatal blockage by pre-existing structures, or synechial shelves and webs blocking normal maxillary antral mucosal flow. The use of nasal antral windows placed anteriorly in the lateral nasal wall at the time of downfracture LeFort (Hosaka window) do not seem to benefit the drainage of the maxillary antrum. This is because physiological flow often bypasses this region. If patients present postoperatively with new sinonasal disease or the aggravation of pre-existing symptoms, evaluation by both endoscopically assisted intranasal and axially and coronal computed tomography (CT) is recommended. Functional endoscopic sinus surgery by the minimally invasive Messerklinger technique, combined with intranasal use of laser-assisted turbinoplasty and soft tissue lysis, have been successfully used for most of these patients. Because the anatomical positioning of the midfacial structure can potentially affect patients with a predisposition to sinonasal physiological disturbances, consideration should be given to preoperative evaluation and discussion of potential consequences.
treatment involved functional, endoscopically assisted sinonasal surgery to clear the ethmoidal and maxillary sinuses involved. It is important that the oral and maxillofacial surgeons consider this possible consequence of midfacial surgery and be familiar with this treatment option should it arise. Both Messerklinger’s technique and that described by Wiegand et al. are based on concepts of reversible disease of the sinus mucosa that will return to normal once adequate drainage has been established.2,3 While Messerklinger focused attempts from anterior to posterior structures and concentrated on the maxillary, ethmoidal and frontal sinuses, Wiegan et al. approached pansinusitis from posterior to anterior with more aggressive eradication. For most patients who have ill effects after LeFort surgery or structural predispositions to secondary blockage of the osteomeatal unit (OMU), the Messerklinger approach is adequate and manageable by the endoscopically trained and adept maxillofacial surgeon. Current endoscopic treatments incorporate knowledge of the physiology of the mucociliary system and its flow patterns as a result of early embryological studies and anatomical justification of sinus treatments (Fig. 1). Ciliary function is both temperature and humidity sensitive; below 18°C and 50% humidity, it is impaired. It there is contact between mucosal surfaces, as can happen with infundibular mucosa swelling, normal ciliary beats of 10–15 strikes/minute
INTRODUCTION The traditional and mid-level LeFort I osteotomy is a common technique used by many surgeons to correct midfacial dentofacial deformities. Because the maxillary osteotomy is made along the nasal floor it has been speculated that breathing may be restricted postoperatively. Hypertrophic turbinates, a deviated septum and other nasal conditions may also obstruct the nose. To avoid such obstruction postoperatively, it is common to do septoplasties and turbinectomies at the same time as the maxillary osteotomy. Others think that maxillary repositioning may contribute to nasal obstruction, particularly with large superior or cephalic impactions. Turvey and Earren, however, assure us that the maxilla may be repositioned without compromising the nasal passageway.1 We believe that the traditional mid-level LeFort I osteotomies done in patients who have a predisposition to sinonasal disease (long face syndrome or midfacial skeletofacial asymmetries) may cause, or aggravate pre-existing, sinus disease by altering the anatomical relations of the sinonasal region. We present here seven cases of postorthognathic aggravation or onset of chronic sinusitis after mid to lower-level LeFort I osteotomies. These involved either osteomeatal complex obstruction by intranasal structural abnormalities, or the blocking of the natural mucus migration patterns of the maxillary sinus by sinus membrane synechiae. The successful 177
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British Journal of Oral and Maxillofacial Surgery
A
Fig. 1 – Diagram of normal mucociliary flow in paranasal sinuses.
can cease altogether. Because these beats are required to move the thicker mucinous blanket along the less viscous layer immediately adjacent to the cilia, it becomes static and provides a culture medium for bacterial infections. A viral symptom can therefore lead to infective bacterial disease within one or two days.4 Alterations in airflow patterns, as are seen occasionally with changes caused by LeFort osteotomies in the nasal region, can also alter the mucosal ciliary response. Structurally, the infundibulum receives drainage from both ethmoidal and frontal sinuses, being joined across the maxillary ostium in the area of the hiatus semilunaris. This region shares space in the middle meatus with the middle turbinate. Ostiae diameters of less than 2.5 mm predispose to infections, primarily because of the phenomenon of ciliae impairment with mucosal approximation (Fig. 2A & B) Additionally, deviation of the superior and middle parts of the septum, swollen or malpositioned turbinates and anatomical variations of the uncinate process can all lead to obstruction, which in turn leads to chronic sinusitis. The focus of endoscopic sinus surgery is the mucociliary system and the location and patency of the ostia and OMU (Fig. 3). We think that mucosal disease is reversible with adequate drainage.5–7 In the following cases, we used the Messerklinger anterior approach after medical management had failed in the treatment of bacterial sinusitis, or when evidence of response to long-term antibiotics was short-lived and there was computed tomographic (CT) evidence of structural elements blocking the OMU.
B Fig. 2 – (A) Diagram of mucosal ciliary pattern with adequate ostial diameter; (B) diagram of ciliary impairment resulting from approximation and inadequate ostial diameter.
INSTRUMENTATION We used a Richards 30° angled endoscope 3.5 mm in diameter attached to a Stryker solid-state video optical enhancement monitoring camera system. We prefer simple instrumentation, to minimize the amount of equipment and assistance required. Most operations are done with straight and 45°-angled WeilBlakesley forceps and a sharp cottle elevator. If it is necessary to resect soft tissue we use a medium ‘ThruCutter’ and medium reverse biting instruments (Smith and Nephew Richards, Inc., Memphis, TN, USA). A curved ostia-seeking probe and suction-assisted sonde are used when approaching the maxillary ostium.
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Fig. 4 – Carbon dioxide laser side beam 45° deflector sheath used for turbinate.
Fig. 3 – Coronally orientated diagram of normal location of the osteomeatal unit structures. 1 = lamina papyracea; 2 = anterior ethmoid; 3 = infundibulum; 4 = uncinate process; 5 = maxillary ostium; 6 = middle meatus = 7 = middle turbinate; and 8 = inferior turbinate.
Endoantral triangulated procedures may also occasionally require the Storz cannula trochar system, 10 F suction catheter tubing and irrigation. We occasionally encounter mucosal haemorrhage despite the injection of local anaesthetic, 0.5% bupivacaine (Marcaine) with adrenaline 1/100 000, and timed nasal Cottonoid packing soaked with 4% cocaine. It is therefore helpful to have insulated electrocautery or laser-assisted (Co2 or Ho-YAG) photocoagulation available. Oral endotracheal intubation is accomplished and vasostrictive packing and injections are accomplished in the usual fashion. The Ho-YAG laser (New Star Laser, Auburn, CA, USA) with quartz fibre-directed bean handpiece was used for endonasal soft tissue ablation, photocoagulation and turbinoplasty of the middle turbinates where indicated, at settings of 10 W of power and filtered plum evacuation. The carbon dioxide laser can also be used, and convenient tips with 45° beveled mirrors are available for directed beam localisations. (Luxar Corporation, Bothell, WA, USA) (Fig. 4). In selected cases, we approach the septoplasty first if the deviated septum or the high and posterior septal spurs either prevent access to the middle meatus, or push the middle turbinate to approximate the lateral nasal wall. This inhibits access to the hiatus semilunaris, uncinate process and infundibulum. Otherwise, the septoplasty is done after the functional endoscopic sinus procedure to reduce the risk of a potential haemorrhage obstructing visibility.
TECHNIQUE If the endoscopic is left distal and out from the middle meatus in the nasal passageway, the surgeon has better access for the instrumentation visibility and control of the instruments. First, the uncinate process is identified and an incision made along it vertically with the sharp edge of the cottle elevator. The uncinate process is then grasped at the superior margin of the incision
with a Wiel-Blakesley forceps and pulled inferiorly to the level of the middle turbinate. These forceps can then be used to open the bulla ethmoidalis, but care must be taken to keep the beaks of the forceps oriented vertically so as not to accidentally stray laterally through the lamina papyracae; this would endanger adjacent ocular adnexal structures. The infundibular decompression caused by this maneuver may require additional surgery to the maxillary ostium, particularly in patients who have had high Le Fort osteotomies with resultant abnormal bony architecture or synechial webbing. A curved probe may help to identify the maxillary ostium. It is then enlarged with a reverse biting forceps anteriorly until the diameter is sufficient (3.0 mm plus). We have found that a curved laser-delivering probe (Co2 Luxar or modified Ho-YAG Coherent) is also useful in reestablishing adequate patency. There are numerous reasons to remove a portion of the middle turbinate in patients with concha bullosa, hypertrophism and paradoxical positioning (or even high posterior septal deviations) that are pushing the middle turbinates into an obstructive position within the OMU. In these cases, both the ‘Thru-Cut’ Richards forceps and the laser-assisted endoscopic nasal turbinoplasty are indicated. Next, a functional silicone stent for endoscopic sinus surgery, bacitracin-coated Telfa strips and nasal drip pads are applied to prevent formation of synechial adhesions and to aid in uneventful mucosal wound healing. If a septoplasty has been done, 4/0 chromic mattress septal sutures are inserted to prevent a septal haematoma, with stenting if necessary. Other routes of access to the antra include the ‘Hosaka window’ (nasal antral window placed previously at the time of the downfractured LeFort osteotomy for later access to the maxillary antrum) (Fig. 5A), and maxillary vestibular–antral trochar– cannula puncture at the area of the canine fossa (Fig. 5B) for removal of transantral polyp, teeth or foreign bodies, and endoscopically assisted laser debridement of reactive mucosa. Openings are usually left open to heal by secondary intention once the instruments have been removed.
COMPLICATIONS AND POSTOPERATIVE CONSIDERATIONS Occasionally nasal irrigation and even steroid nasal sprays are required postoperatively after the pack and
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A
Fig. 6 – Speculum-assisted intranasal examination showing polypoid mass (case 1).
B Fig. 5 – (A)Diagram of down grafted maxilla at LeFort I level and placement of notches on lateral nasal walls for Hosaka window access to maxillary antrum; (B) Canine fossa approach used for alternative access to maxillary antrum. Fig. 7 – Coronal CT (case 1) showing polypoid mass and concha bullosa.
stent have been removed. Antibiotics are given routinely to all patients. Endonasal examinations are made with a headlight and speculum postoperatively to inspect for early synechial formation, as these can often be interrupted with antibiotic-coated cotton applicators or minimal manipulation. More mature adhesions may require surgical or laser-assisted lysis.
CASE 1 A 42-year-old white man gave a history of segmental LeFort I osteotomy combined with mandibular osteotomy, septoplasty and partial turbinectomies for facial skeletal asymmetry, vertical maxillary hyperplasia and retrognathism; he had obstructive nasal respirations caused by septal deviation and hypertrophic turbinates. Examination at the time of the LeFort I showed a cyst in the left maxillary antrum and severe septal spurs and deviations. Histological examination was consistent with a cholesterol granuloma.
Within two to three weeks postoperatively, the patient reported a large obstruction in the right nasal passageway, which turned out to be a polypoid mass (Fig.6); he was treated with nasal topical steroids. These failed to remove the obstruction though it reduced in size, and a CT was ordered that showed a large (2–3 cm) oblong soft tissue mass in the right lateral aspect of the nasal cavity (Fig. 7). The polyp was removed by functional endoscopically assisted nasal surgery followed by Ho-YAG laser ablation of remaining soft tissue tags. Histopathological examination confirmed polyps and a mucus-retention cyst with mucus gland hyperplasia. Postoperatively he was given intranasal steroids and there have been no recurrences in the past 14 months.
CASE 2 A 54-year-old white woman presented having had multiple facial osteotomies (segmental LeFort I and mandibular
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B
Fig. 8 – A Preoperative cephalometric film (case 2) showing long face syndrome with apertognathia. (B) Postoperative cephalometric film (case 2) after skeletofacial osteotomies.
hypoplasia. The obstructive nasal respiration did not respond to conservative medical management and there were physical signs of septal deviation with bone spurs and compensatory hypertrophic turbinates. He was operated on in 1995. Postoperatively he developed unrelated communityacquired pneumonia and was treated medically for several months. At follow-up examination he complained of excessive nasal drainage, feelings of congestion in the sinuses and headaches. CT showed concha bullosa of the middle meatus that was interfering with the OMU. Despite large, patent nasoantral ‘Hosaka windows’ the physiological movements of the mucus within the maxillary antrum were obstructed at the ostium and abnormal flow resulted in pooling within the maxillary sinus (Fig. 10a,b).
Fig. 9 – Coronal CT (case 2) showing concha bullosa, invaginating inferior turbinates and blocked osteomeatal units.
osteotomies) for correction of posterior vertical maxillary hyperplasia with apertognathism and retrognathism (Fig. 8A,B). There were polyps in the maxillary nasal sinuses which histologically were inflammatory polyps with increased number of eosinophils in the nasal mucosa. Several years later, she returned complaining of headaches and chronic sinusitis that was resistant to medical management. CT showed extensive inflammatory changes in the left maxillary sinus which extended through the ethmoidal air cells. The OMU was blocked on the left side along with a concha bullosa, blockage of the OMU and hypertrophied turbinates of the right side (Fig. 9). We planned functional endoscopic sinus surgery with opening of the maxillary ostium and OMU with anterior ethmoidectomy; she also had ‘Thru-Cut’ instrumentation and HoYAGI laser-assisted turbinoplasty, and unrestricted carbon dioxide laser-assisted uvulopalatoplasty.
CASE 3 This patient had had temporomandibular joint (TMJ) chondrocalcinosis treated by arthroscopic surgery in 1992 with adequate rehabilitation. Skeletofacial dysplasia consisted of maxillary asymmetry, apertognathism and mandibular
CASE 4 A 21-year-old white woman was operated on in 1992, when she had bilateral TMJ arthroscopic procedures done at the same time as superior repositioning LeFort I osteotomies/ ostectomies. She also required septoplasty and inferior turbinectomies for treatment of obstructive nasal respiration, septal deviation and hypertrophic inferior turbinates. CT showed that the uncinate process was deviated to one side and there was a small antral window on the inferior aspect of the right maxillary sinus. Endonasal examination showed hypertrophic middle meatal turbinates with blockage. She also had a history of occasional swelling of the left cheek with sinusitis. She was treated with functional endoscopic sinus surgery and laser-assisted turbinoplasty to clear the middle meatus.
CASE 5 A 26-year-old white woman had had multiple surgical procedures, including arthroscopic and open TMJ surgery as well as segmental LeFort I osteotomies between 1988 and 1991. In addition to the TM dysfunction, she had apertognathia and chronic sinusitis that did not respond to antibiotics and other medical management before the osteotomies. Preoperatively, physical and cephalometric examinations showed posterior vertical maxillary hyperplasia leading to the apertognathia. Intranasal examination showed hypertrophied inferior
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A
B
Fig. 10 – (A) Coronal CT (case 3) showing blocked osteomeatal units and evidence of LeFort I fixation; (B) Coronal CT (case 3) showing left concha bullosa and lack of maxillary antral mucus drainage even through a patent Hosaka antral window. This illustrated the need for a functioning osteomeatal unit.
A
B
Fig. 11 – (A) Coronal CT (case 5) showing blockage of nasal passageways and osteomeatal units; (B) Coronal CT (case 5) showing adhesion of turbinate in middle meatus, blockage of osteomeatal unit and patent Hosaka antral windows.
turbinates that did not respond to nasostrictive sprays. When symptoms of sinusitis and rhinitis worsened postoperatively, she returned for re-evaluation, and CT showed complete blockage of the OMU with hypertrophy of the middle and inferior turbinates, and adhesions between the left middle turbinates and lateral wall that were completely blocking the middle meatus (Fig. 11A,B). Functional endoscopic sinus surgery treatment included bilateral ethmoidectomies and maxillary antrostomies by the Messerklinger approach as described earlier, and postoperatively middle meatal Merocel turbinate stents coated with Muralube were used to help prevent further adhesions. This treatment was unsuccessful and secondary intervention with more aggressive laser-assisted turbinate ablation is planned.
turbinectomies and septoplasty for posterior vertical maxillary hyperplasia with resultant apertognathia, mandibular asymmetric prognathism and concurrent hypertrophic turbinates with obstructive nasal respirations. She returned in 1995 complaining of sinusitis and chronic nasal rhinorrhea. A combination of endoscopically assisted endonasal examination and CT showed blockage of the maxillary ostium by a synechial web resulting in physiological restriction of the flow of maxillary sinus mucus despite the patency of a large nasal antral window placed at the time of the original LeFort I osteotomy (Hosaka window) (Fig. 12).
CASE 7 CASE 6 A 35-year-old white woman was treated in 1987 with TMJ arthroscopic surgery for TM dysfunction with internal joint derangement, and in 1989 had a LeFort I osteotomy with superior repositioning, sagittal split ramus osteotomy,
A 44-year-old white woman had had orthognathic surgery in 1991 with maxillary and mandibular osteotomies including septoplasty and turbinectomy in December; and in 1993 for treatment of maxillary hyperplasia, skeletofacial asymmetry with a shift to the left, mandibular anteroposterior hypoplasia, hypertrophy of the left inferior turbinate and
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Fig. 12 – Coronal CT (case 6) showing lack of physiological flow of mucus in maxillary antrum (and fill) despite patent Hosaka antral window.
chronic nasal congestion with obstructive nasal respiration. She had had temporomandibular joint dysfunction in the past, which was also thought to be related to the skeletofacial asymmetry and structural compensatory loading excess. She returned to our clinic complaining of excessive drainage of the maxillary sinus and nasal congestion. She was first treated with decongestants and antibiotics for an extended period of time without relief of symptoms. CT of the paranasal sinuses in January 1995 showed mucosal thickening involving the medial and lateral maxillary wall and obstruction of the OMU with resulting buildup of mucus in the maxillary sinuses despite patent maxillary antral windows placed at the time of the LeFort I (Hosaka window technique). She underwent endoscopic removal of the soft tissue synechiae and opening of the infundibulum bilaterally, and widening of the natural maxillary ostium anteriorly.
A
HOSAKA WINDOW TECHNIQUE B During the course of downfracture of the maxillary during LeFort I procedures, patients with chronic sinusitis and obstructive nasal respirations who are having rigid fixation have notches made in the lateral nasal walls at the junction of the medial maxillary and lateral nasal walls in the anterior aspect of the maxillary antrum (Fig. 5A (arrow). This is done with a curved-tip bone rongeurs to allow the potential drainage of the maxillary antrum during healing. We also used this window to make it easier to place small endoscopes postoperatively (Fig. 13A,B). It allows a view of the nasal sinus mucosa and its response to the protruding screws from the rigid fixation, shows relative healing of the osteotomy sites and gives the ability to insert bone or hydroxyapatite block grafts, check for mucosal webs or plicae which may have inhibited physiological flow patters of mucus.
RESULTS Examination of the maxillary antral walls through the ‘Hosaka window’ showed in most cases the absence of
Fig. 13 – (A) Diagram of Storz cannula trochar system inserted through Hosaka window in nasal sill; (B) Photograph of Storz cannula guiding the endoscope into the maxillary antrum to view synechial web and shelf.
disease mucosa in approximation to the maxillary rigid fixation screw that was protruding into the sinus. This was true whether or not titanium alloy or stainless steel screws were used. By using the 70° endoscope and rotating it carefully for better visualization, we saw that three of our seven patients had horizontal synechial webs and shelves secondary to the LeFort I osteotomy site in the maxillary antrum, possibly leading to a ‘fall back’ inhibition of normal physiological flow of mucus towards the natural ostium (Fig. 14). Three of these patients required lysis of the synechial webs at the level of the maxillary ostium to regain appropriate aeration of the maxillary sinus. Other aetiological factors may have been pre-existing contributors or predisposing anatomical variants,
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References 1. 2. 3. 4.
5. 6.
7. 8. Fig. 14 – Diagram of a shelf and plica contributing to ‘fall-back’ phenomenon that inhibits the flow pattern towards the natural ostium of the maxillary sinus.
including enlargement of concha bullosa in the middle meatus that inhibited ciliary movement at the hiatus semilunaris and infundibulum (Fig. 6). The presence of high septal spurs and asymmetric deviations may also have led to predisposing narrowed passageways and drainage spaces which were unable to deal with the altered airflow pattern following orthognathic surgery. Whereas airways with normal anatomy and healthy mucosa may have been able to tolerate these changes, the already compromised mucosa and airways in patients with chronic obstructive nasal respiration may not be able to adapt quickly enough. These cases seem to be more likely among patients presenting with the classic apertognathia and posterior vertical maxillary hyperplasia with mouth breathing.
Turvey TA, Earren DW. Impact of maxillary osteotomies on nasal breathing: orthognathic surgery. Oral Maxillofac Surg Clin N Am 1990; 2:831–841. Messerklinger E. Endoskopische Diagnose und Chirurgie derrezidivierenden Sinusitis. In: Krajina Z, ed. Advances in Nose and Sinus Surgery Zagreb: Zagreb University, 1985. Wiegand ME, Steiner W, Jaumann MP. Endonasal sinus surgery with endoscopical control: from radical operation to rehabilitation of the mucosa. Endoscopy 1978; 10:255–260. Lucas AM, Douglas LC. Principles underlying ciliary activity in the respiratory tract. II. A comparison of nasal clearance in man, monkey and other mammals. Arch Otolaryngol 1934; 20:518–541. Stammberger H. Endoscopic surgery for a cystic and chronic recurring sinusitis. Ann Otol Rhinol Laryngol 1985; 119 (Suppl):11. Stammberger H. Endoscopic endonasal surgery – concepts in treatment of recurring rhinosinusitis. Part I. Anatomic and pathopysiologic considerations. Otolaryngol Head Neck Surg 1986; 94:143–155. Stammberger H. Endoscopic endonasal surgery – concepts in treatment of recurring rhinosinusitis. II Surgical technique. Otolaryngol Head Neck Surg 1986; 94:147–156. Simon E. Anatomy of the opening of the maxillary sinus. Arch Otol 1933; 29:640–649.
The Authors Jeffrey J. Moses DDS Medical Director Antonio Arredondo DDS Post-Doctoral Fellow Pacific Clinical Research Foundation Encinitas, CA, USA Claus R. Lange MD DMD Resident Physician Department of Maxillofacial Plastic Surgery University of Lubeck Lubeck, Germany Correspondence and requests for offprints to: Jeffrey J. Moses DDS, Medical Director, Pacific Clinical Research Foundation, 355 Santa Fe Drive, Suite 100, Encinitas, CA 92024, USA Paper received 18 February 1999 Accepted 29 March 1999
BRITISH JOURNAL OF ORAL
& M A X I L L O FA C I A L S U R G E RY
Endoscopic treatment of sinonasal disease in patients who have had orthognathic surgery J. J. Moses, C. R. Lange,* A. Arredondo† Medical Director; †Post-Doctoral Fellow, Pacific Clinical Research Foundation, Encinitas, CA, USA; *Resident Physician, Department of Maxillofacial Plastic Surgery, University of Lubeck, Lubeck, Germany SUMMARY. Certain skeletofacial patterns may be predisposed to aggravated sinonasal disease postoperatively. These may include, but are not limited to, facial skeletal asymmetries with high septal deviations and those with obstructive nasal respiration and mouth breathing that leads to skeletal growth disturbances such as vertical maxillary hyperplasia and apertognathism. These sinonasal diseases may partly be the result of osteomeatal blockage by pre-existing structures, or synechial shelves and webs blocking normal maxillary antral mucosal flow. The use of nasal antral windows placed anteriorly in the lateral nasal wall at the time of downfracture LeFort (Hosaka window) do not seem to benefit the drainage of the maxillary antrum. This is because physiological flow often bypasses this region. If patients present postoperatively with new sinonasal disease or the aggravation of pre-existing symptoms, evaluation by both endoscopically assisted intranasal and axially and coronal computed tomography (CT) is recommended. Functional endoscopic sinus surgery by the minimally invasive Messerklinger technique, combined with intranasal use of laser-assisted turbinoplasty and soft tissue lysis, have been successfully used for most of these patients. Because the anatomical positioning of the midfacial structure can potentially affect patients with a predisposition to sinonasal physiological disturbances, consideration should be given to preoperative evaluation and discussion of potential consequences.
treatment involved functional, endoscopically assisted sinonasal surgery to clear the ethmoidal and maxillary sinuses involved. It is important that the oral and maxillofacial surgeons consider this possible consequence of midfacial surgery and be familiar with this treatment option should it arise. Both Messerklinger’s technique and that described by Wiegand et al. are based on concepts of reversible disease of the sinus mucosa that will return to normal once adequate drainage has been established.2,3 While Messerklinger focused attempts from anterior to posterior structures and concentrated on the maxillary, ethmoidal and frontal sinuses, Wiegan et al. approached pansinusitis from posterior to anterior with more aggressive eradication. For most patients who have ill effects after LeFort surgery or structural predispositions to secondary blockage of the osteomeatal unit (OMU), the Messerklinger approach is adequate and manageable by the endoscopically trained and adept maxillofacial surgeon. Current endoscopic treatments incorporate knowledge of the physiology of the mucociliary system and its flow patterns as a result of early embryological studies and anatomical justification of sinus treatments (Fig. 1). Ciliary function is both temperature and humidity sensitive; below 18°C and 50% humidity, it is impaired. It there is contact between mucosal surfaces, as can happen with infundibular mucosa swelling, normal ciliary beats of 10–15 strikes/minute
INTRODUCTION The traditional and mid-level LeFort I osteotomy is a common technique used by many surgeons to correct midfacial dentofacial deformities. Because the maxillary osteotomy is made along the nasal floor it has been speculated that breathing may be restricted postoperatively. Hypertrophic turbinates, a deviated septum and other nasal conditions may also obstruct the nose. To avoid such obstruction postoperatively, it is common to do septoplasties and turbinectomies at the same time as the maxillary osteotomy. Others think that maxillary repositioning may contribute to nasal obstruction, particularly with large superior or cephalic impactions. Turvey and Earren, however, assure us that the maxilla may be repositioned without compromising the nasal passageway.1 We believe that the traditional mid-level LeFort I osteotomies done in patients who have a predisposition to sinonasal disease (long face syndrome or midfacial skeletofacial asymmetries) may cause, or aggravate pre-existing, sinus disease by altering the anatomical relations of the sinonasal region. We present here seven cases of postorthognathic aggravation or onset of chronic sinusitis after mid to lower-level LeFort I osteotomies. These involved either osteomeatal complex obstruction by intranasal structural abnormalities, or the blocking of the natural mucus migration patterns of the maxillary sinus by sinus membrane synechiae. The successful 177
178
British Journal of Oral and Maxillofacial Surgery
A
Fig. 1 – Diagram of normal mucociliary flow in paranasal sinuses.
can cease altogether. Because these beats are required to move the thicker mucinous blanket along the less viscous layer immediately adjacent to the cilia, it becomes static and provides a culture medium for bacterial infections. A viral symptom can therefore lead to infective bacterial disease within one or two days.4 Alterations in airflow patterns, as are seen occasionally with changes caused by LeFort osteotomies in the nasal region, can also alter the mucosal ciliary response. Structurally, the infundibulum receives drainage from both ethmoidal and frontal sinuses, being joined across the maxillary ostium in the area of the hiatus semilunaris. This region shares space in the middle meatus with the middle turbinate. Ostiae diameters of less than 2.5 mm predispose to infections, primarily because of the phenomenon of ciliae impairment with mucosal approximation (Fig. 2A & B) Additionally, deviation of the superior and middle parts of the septum, swollen or malpositioned turbinates and anatomical variations of the uncinate process can all lead to obstruction, which in turn leads to chronic sinusitis. The focus of endoscopic sinus surgery is the mucociliary system and the location and patency of the ostia and OMU (Fig. 3). We think that mucosal disease is reversible with adequate drainage.5–7 In the following cases, we used the Messerklinger anterior approach after medical management had failed in the treatment of bacterial sinusitis, or when evidence of response to long-term antibiotics was short-lived and there was computed tomographic (CT) evidence of structural elements blocking the OMU.
B Fig. 2 – (A) Diagram of mucosal ciliary pattern with adequate ostial diameter; (B) diagram of ciliary impairment resulting from approximation and inadequate ostial diameter.
INSTRUMENTATION We used a Richards 30° angled endoscope 3.5 mm in diameter attached to a Stryker solid-state video optical enhancement monitoring camera system. We prefer simple instrumentation, to minimize the amount of equipment and assistance required. Most operations are done with straight and 45°-angled WeilBlakesley forceps and a sharp cottle elevator. If it is necessary to resect soft tissue we use a medium ‘ThruCutter’ and medium reverse biting instruments (Smith and Nephew Richards, Inc., Memphis, TN, USA). A curved ostia-seeking probe and suction-assisted sonde are used when approaching the maxillary ostium.
Endoscopic treatment of sinonasal disease after orthognathic surgery
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Fig. 4 – Carbon dioxide laser side beam 45° deflector sheath used for turbinate.
Fig. 3 – Coronally orientated diagram of normal location of the osteomeatal unit structures. 1 = lamina papyracea; 2 = anterior ethmoid; 3 = infundibulum; 4 = uncinate process; 5 = maxillary ostium; 6 = middle meatus = 7 = middle turbinate; and 8 = inferior turbinate.
Endoantral triangulated procedures may also occasionally require the Storz cannula trochar system, 10 F suction catheter tubing and irrigation. We occasionally encounter mucosal haemorrhage despite the injection of local anaesthetic, 0.5% bupivacaine (Marcaine) with adrenaline 1/100 000, and timed nasal Cottonoid packing soaked with 4% cocaine. It is therefore helpful to have insulated electrocautery or laser-assisted (Co2 or Ho-YAG) photocoagulation available. Oral endotracheal intubation is accomplished and vasostrictive packing and injections are accomplished in the usual fashion. The Ho-YAG laser (New Star Laser, Auburn, CA, USA) with quartz fibre-directed bean handpiece was used for endonasal soft tissue ablation, photocoagulation and turbinoplasty of the middle turbinates where indicated, at settings of 10 W of power and filtered plum evacuation. The carbon dioxide laser can also be used, and convenient tips with 45° beveled mirrors are available for directed beam localisations. (Luxar Corporation, Bothell, WA, USA) (Fig. 4). In selected cases, we approach the septoplasty first if the deviated septum or the high and posterior septal spurs either prevent access to the middle meatus, or push the middle turbinate to approximate the lateral nasal wall. This inhibits access to the hiatus semilunaris, uncinate process and infundibulum. Otherwise, the septoplasty is done after the functional endoscopic sinus procedure to reduce the risk of a potential haemorrhage obstructing visibility.
TECHNIQUE If the endoscopic is left distal and out from the middle meatus in the nasal passageway, the surgeon has better access for the instrumentation visibility and control of the instruments. First, the uncinate process is identified and an incision made along it vertically with the sharp edge of the cottle elevator. The uncinate process is then grasped at the superior margin of the incision
with a Wiel-Blakesley forceps and pulled inferiorly to the level of the middle turbinate. These forceps can then be used to open the bulla ethmoidalis, but care must be taken to keep the beaks of the forceps oriented vertically so as not to accidentally stray laterally through the lamina papyracae; this would endanger adjacent ocular adnexal structures. The infundibular decompression caused by this maneuver may require additional surgery to the maxillary ostium, particularly in patients who have had high Le Fort osteotomies with resultant abnormal bony architecture or synechial webbing. A curved probe may help to identify the maxillary ostium. It is then enlarged with a reverse biting forceps anteriorly until the diameter is sufficient (3.0 mm plus). We have found that a curved laser-delivering probe (Co2 Luxar or modified Ho-YAG Coherent) is also useful in reestablishing adequate patency. There are numerous reasons to remove a portion of the middle turbinate in patients with concha bullosa, hypertrophism and paradoxical positioning (or even high posterior septal deviations) that are pushing the middle turbinates into an obstructive position within the OMU. In these cases, both the ‘Thru-Cut’ Richards forceps and the laser-assisted endoscopic nasal turbinoplasty are indicated. Next, a functional silicone stent for endoscopic sinus surgery, bacitracin-coated Telfa strips and nasal drip pads are applied to prevent formation of synechial adhesions and to aid in uneventful mucosal wound healing. If a septoplasty has been done, 4/0 chromic mattress septal sutures are inserted to prevent a septal haematoma, with stenting if necessary. Other routes of access to the antra include the ‘Hosaka window’ (nasal antral window placed previously at the time of the downfractured LeFort osteotomy for later access to the maxillary antrum) (Fig. 5A), and maxillary vestibular–antral trochar– cannula puncture at the area of the canine fossa (Fig. 5B) for removal of transantral polyp, teeth or foreign bodies, and endoscopically assisted laser debridement of reactive mucosa. Openings are usually left open to heal by secondary intention once the instruments have been removed.
COMPLICATIONS AND POSTOPERATIVE CONSIDERATIONS Occasionally nasal irrigation and even steroid nasal sprays are required postoperatively after the pack and
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Fig. 6 – Speculum-assisted intranasal examination showing polypoid mass (case 1).
B Fig. 5 – (A)Diagram of down grafted maxilla at LeFort I level and placement of notches on lateral nasal walls for Hosaka window access to maxillary antrum; (B) Canine fossa approach used for alternative access to maxillary antrum. Fig. 7 – Coronal CT (case 1) showing polypoid mass and concha bullosa.
stent have been removed. Antibiotics are given routinely to all patients. Endonasal examinations are made with a headlight and speculum postoperatively to inspect for early synechial formation, as these can often be interrupted with antibiotic-coated cotton applicators or minimal manipulation. More mature adhesions may require surgical or laser-assisted lysis.
CASE 1 A 42-year-old white man gave a history of segmental LeFort I osteotomy combined with mandibular osteotomy, septoplasty and partial turbinectomies for facial skeletal asymmetry, vertical maxillary hyperplasia and retrognathism; he had obstructive nasal respirations caused by septal deviation and hypertrophic turbinates. Examination at the time of the LeFort I showed a cyst in the left maxillary antrum and severe septal spurs and deviations. Histological examination was consistent with a cholesterol granuloma.
Within two to three weeks postoperatively, the patient reported a large obstruction in the right nasal passageway, which turned out to be a polypoid mass (Fig.6); he was treated with nasal topical steroids. These failed to remove the obstruction though it reduced in size, and a CT was ordered that showed a large (2–3 cm) oblong soft tissue mass in the right lateral aspect of the nasal cavity (Fig. 7). The polyp was removed by functional endoscopically assisted nasal surgery followed by Ho-YAG laser ablation of remaining soft tissue tags. Histopathological examination confirmed polyps and a mucus-retention cyst with mucus gland hyperplasia. Postoperatively he was given intranasal steroids and there have been no recurrences in the past 14 months.
CASE 2 A 54-year-old white woman presented having had multiple facial osteotomies (segmental LeFort I and mandibular
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Fig. 8 – A Preoperative cephalometric film (case 2) showing long face syndrome with apertognathia. (B) Postoperative cephalometric film (case 2) after skeletofacial osteotomies.
hypoplasia. The obstructive nasal respiration did not respond to conservative medical management and there were physical signs of septal deviation with bone spurs and compensatory hypertrophic turbinates. He was operated on in 1995. Postoperatively he developed unrelated communityacquired pneumonia and was treated medically for several months. At follow-up examination he complained of excessive nasal drainage, feelings of congestion in the sinuses and headaches. CT showed concha bullosa of the middle meatus that was interfering with the OMU. Despite large, patent nasoantral ‘Hosaka windows’ the physiological movements of the mucus within the maxillary antrum were obstructed at the ostium and abnormal flow resulted in pooling within the maxillary sinus (Fig. 10a,b).
Fig. 9 – Coronal CT (case 2) showing concha bullosa, invaginating inferior turbinates and blocked osteomeatal units.
osteotomies) for correction of posterior vertical maxillary hyperplasia with apertognathism and retrognathism (Fig. 8A,B). There were polyps in the maxillary nasal sinuses which histologically were inflammatory polyps with increased number of eosinophils in the nasal mucosa. Several years later, she returned complaining of headaches and chronic sinusitis that was resistant to medical management. CT showed extensive inflammatory changes in the left maxillary sinus which extended through the ethmoidal air cells. The OMU was blocked on the left side along with a concha bullosa, blockage of the OMU and hypertrophied turbinates of the right side (Fig. 9). We planned functional endoscopic sinus surgery with opening of the maxillary ostium and OMU with anterior ethmoidectomy; she also had ‘Thru-Cut’ instrumentation and HoYAGI laser-assisted turbinoplasty, and unrestricted carbon dioxide laser-assisted uvulopalatoplasty.
CASE 3 This patient had had temporomandibular joint (TMJ) chondrocalcinosis treated by arthroscopic surgery in 1992 with adequate rehabilitation. Skeletofacial dysplasia consisted of maxillary asymmetry, apertognathism and mandibular
CASE 4 A 21-year-old white woman was operated on in 1992, when she had bilateral TMJ arthroscopic procedures done at the same time as superior repositioning LeFort I osteotomies/ ostectomies. She also required septoplasty and inferior turbinectomies for treatment of obstructive nasal respiration, septal deviation and hypertrophic inferior turbinates. CT showed that the uncinate process was deviated to one side and there was a small antral window on the inferior aspect of the right maxillary sinus. Endonasal examination showed hypertrophic middle meatal turbinates with blockage. She also had a history of occasional swelling of the left cheek with sinusitis. She was treated with functional endoscopic sinus surgery and laser-assisted turbinoplasty to clear the middle meatus.
CASE 5 A 26-year-old white woman had had multiple surgical procedures, including arthroscopic and open TMJ surgery as well as segmental LeFort I osteotomies between 1988 and 1991. In addition to the TM dysfunction, she had apertognathia and chronic sinusitis that did not respond to antibiotics and other medical management before the osteotomies. Preoperatively, physical and cephalometric examinations showed posterior vertical maxillary hyperplasia leading to the apertognathia. Intranasal examination showed hypertrophied inferior
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Fig. 10 – (A) Coronal CT (case 3) showing blocked osteomeatal units and evidence of LeFort I fixation; (B) Coronal CT (case 3) showing left concha bullosa and lack of maxillary antral mucus drainage even through a patent Hosaka antral window. This illustrated the need for a functioning osteomeatal unit.
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Fig. 11 – (A) Coronal CT (case 5) showing blockage of nasal passageways and osteomeatal units; (B) Coronal CT (case 5) showing adhesion of turbinate in middle meatus, blockage of osteomeatal unit and patent Hosaka antral windows.
turbinates that did not respond to nasostrictive sprays. When symptoms of sinusitis and rhinitis worsened postoperatively, she returned for re-evaluation, and CT showed complete blockage of the OMU with hypertrophy of the middle and inferior turbinates, and adhesions between the left middle turbinates and lateral wall that were completely blocking the middle meatus (Fig. 11A,B). Functional endoscopic sinus surgery treatment included bilateral ethmoidectomies and maxillary antrostomies by the Messerklinger approach as described earlier, and postoperatively middle meatal Merocel turbinate stents coated with Muralube were used to help prevent further adhesions. This treatment was unsuccessful and secondary intervention with more aggressive laser-assisted turbinate ablation is planned.
turbinectomies and septoplasty for posterior vertical maxillary hyperplasia with resultant apertognathia, mandibular asymmetric prognathism and concurrent hypertrophic turbinates with obstructive nasal respirations. She returned in 1995 complaining of sinusitis and chronic nasal rhinorrhea. A combination of endoscopically assisted endonasal examination and CT showed blockage of the maxillary ostium by a synechial web resulting in physiological restriction of the flow of maxillary sinus mucus despite the patency of a large nasal antral window placed at the time of the original LeFort I osteotomy (Hosaka window) (Fig. 12).
CASE 7 CASE 6 A 35-year-old white woman was treated in 1987 with TMJ arthroscopic surgery for TM dysfunction with internal joint derangement, and in 1989 had a LeFort I osteotomy with superior repositioning, sagittal split ramus osteotomy,
A 44-year-old white woman had had orthognathic surgery in 1991 with maxillary and mandibular osteotomies including septoplasty and turbinectomy in December; and in 1993 for treatment of maxillary hyperplasia, skeletofacial asymmetry with a shift to the left, mandibular anteroposterior hypoplasia, hypertrophy of the left inferior turbinate and
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Fig. 12 – Coronal CT (case 6) showing lack of physiological flow of mucus in maxillary antrum (and fill) despite patent Hosaka antral window.
chronic nasal congestion with obstructive nasal respiration. She had had temporomandibular joint dysfunction in the past, which was also thought to be related to the skeletofacial asymmetry and structural compensatory loading excess. She returned to our clinic complaining of excessive drainage of the maxillary sinus and nasal congestion. She was first treated with decongestants and antibiotics for an extended period of time without relief of symptoms. CT of the paranasal sinuses in January 1995 showed mucosal thickening involving the medial and lateral maxillary wall and obstruction of the OMU with resulting buildup of mucus in the maxillary sinuses despite patent maxillary antral windows placed at the time of the LeFort I (Hosaka window technique). She underwent endoscopic removal of the soft tissue synechiae and opening of the infundibulum bilaterally, and widening of the natural maxillary ostium anteriorly.
A
HOSAKA WINDOW TECHNIQUE B During the course of downfracture of the maxillary during LeFort I procedures, patients with chronic sinusitis and obstructive nasal respirations who are having rigid fixation have notches made in the lateral nasal walls at the junction of the medial maxillary and lateral nasal walls in the anterior aspect of the maxillary antrum (Fig. 5A (arrow). This is done with a curved-tip bone rongeurs to allow the potential drainage of the maxillary antrum during healing. We also used this window to make it easier to place small endoscopes postoperatively (Fig. 13A,B). It allows a view of the nasal sinus mucosa and its response to the protruding screws from the rigid fixation, shows relative healing of the osteotomy sites and gives the ability to insert bone or hydroxyapatite block grafts, check for mucosal webs or plicae which may have inhibited physiological flow patters of mucus.
RESULTS Examination of the maxillary antral walls through the ‘Hosaka window’ showed in most cases the absence of
Fig. 13 – (A) Diagram of Storz cannula trochar system inserted through Hosaka window in nasal sill; (B) Photograph of Storz cannula guiding the endoscope into the maxillary antrum to view synechial web and shelf.
disease mucosa in approximation to the maxillary rigid fixation screw that was protruding into the sinus. This was true whether or not titanium alloy or stainless steel screws were used. By using the 70° endoscope and rotating it carefully for better visualization, we saw that three of our seven patients had horizontal synechial webs and shelves secondary to the LeFort I osteotomy site in the maxillary antrum, possibly leading to a ‘fall back’ inhibition of normal physiological flow of mucus towards the natural ostium (Fig. 14). Three of these patients required lysis of the synechial webs at the level of the maxillary ostium to regain appropriate aeration of the maxillary sinus. Other aetiological factors may have been pre-existing contributors or predisposing anatomical variants,
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References 1. 2. 3. 4.
5. 6.
7. 8. Fig. 14 – Diagram of a shelf and plica contributing to ‘fall-back’ phenomenon that inhibits the flow pattern towards the natural ostium of the maxillary sinus.
including enlargement of concha bullosa in the middle meatus that inhibited ciliary movement at the hiatus semilunaris and infundibulum (Fig. 6). The presence of high septal spurs and asymmetric deviations may also have led to predisposing narrowed passageways and drainage spaces which were unable to deal with the altered airflow pattern following orthognathic surgery. Whereas airways with normal anatomy and healthy mucosa may have been able to tolerate these changes, the already compromised mucosa and airways in patients with chronic obstructive nasal respiration may not be able to adapt quickly enough. These cases seem to be more likely among patients presenting with the classic apertognathia and posterior vertical maxillary hyperplasia with mouth breathing.
Turvey TA, Earren DW. Impact of maxillary osteotomies on nasal breathing: orthognathic surgery. Oral Maxillofac Surg Clin N Am 1990; 2:831–841. Messerklinger E. Endoskopische Diagnose und Chirurgie derrezidivierenden Sinusitis. In: Krajina Z, ed. Advances in Nose and Sinus Surgery Zagreb: Zagreb University, 1985. Wiegand ME, Steiner W, Jaumann MP. Endonasal sinus surgery with endoscopical control: from radical operation to rehabilitation of the mucosa. Endoscopy 1978; 10:255–260. Lucas AM, Douglas LC. Principles underlying ciliary activity in the respiratory tract. II. A comparison of nasal clearance in man, monkey and other mammals. Arch Otolaryngol 1934; 20:518–541. Stammberger H. Endoscopic surgery for a cystic and chronic recurring sinusitis. Ann Otol Rhinol Laryngol 1985; 119 (Suppl):11. Stammberger H. Endoscopic endonasal surgery – concepts in treatment of recurring rhinosinusitis. Part I. Anatomic and pathopysiologic considerations. Otolaryngol Head Neck Surg 1986; 94:143–155. Stammberger H. Endoscopic endonasal surgery – concepts in treatment of recurring rhinosinusitis. II Surgical technique. Otolaryngol Head Neck Surg 1986; 94:147–156. Simon E. Anatomy of the opening of the maxillary sinus. Arch Otol 1933; 29:640–649.
The Authors Jeffrey J. Moses DDS Medical Director Antonio Arredondo DDS Post-Doctoral Fellow Pacific Clinical Research Foundation Encinitas, CA, USA Claus R. Lange MD DMD Resident Physician Department of Maxillofacial Plastic Surgery University of Lubeck Lubeck, Germany Correspondence and requests for offprints to: Jeffrey J. Moses DDS, Medical Director, Pacific Clinical Research Foundation, 355 Santa Fe Drive, Suite 100, Encinitas, CA 92024, USA Paper received 18 February 1999 Accepted 29 March 1999