Abstract
The condition of the maxillary sinus is not routinely assessed before a Le Fort I osteotomy. Performing this procedure in an infected sinus might account for a considerable proportion of the complications, such as excessive bleeding and sinusitis. The aim of this study was to evaluate the maxillary sinus and nasal ventilation after Le Fort I osteotomy. Twenty patients were evaluated before and 2 months after surgery using validated questionnaires for sinonasal complaints (RSOM-31 and VAS score), nasal endoscopy, peak nasal inspiratory flow (PNIF), and a computed tomography (CT) scan. There were no differences in complaints before and 2 months after surgery ( P > 0.24). Also, the PNIF did not change significantly ( P = 0.10). On CT evaluation before surgery, a previously unnoted sinusitis was diagnosed in two patients. Postoperatively, a thickened sinus mucosa was present in all patients near the osteotomy line, the osteosyntheses, and around sequesters. This report describes maxillary sinus evaluation after Le Fort I osteotomy in a more comprehensive way by using CT. The Le Fort I procedure did not influence already existing physical or mental complaints, and nasal ventilation was not negatively affected. However, evaluation of sinonasal pathology should be emphasized in the preoperative work-up.
The horizontal maxillary osteotomy was first described by Von Langenbeck in 1859 for removal of a nasopharyngeal tumor. This procedure, now also known as the Le Fort I osteotomy after the description of natural maxillary fracture planes by Le Fort in 1901, has become a routine procedure in maxillofacial and plastic surgery. The procedure involves temporary disconnection of the complete maxilla from the midface.
Despite the high incidence of sinusitis, affecting 16% of the population annually, the condition of the maxillary sinus is not routinely assessed before a Le Fort I osteotomy. Performing this procedure in an infected sinus might account for a considerable proportion of the complications during or after surgery, such as excessive bleeding and exacerbation of pre-existing (asymptomatic) sinusitis. Moreover, individual variations in anatomy are not routinely checked before surgery. An asymmetric nasal septum or extra ostium in the sinus might affect the postoperative functional outcome because of damage to the sinonasal airflow and mucous drainage system.
However, healing after surgery is generally uneventful. Complications occur in 6.4–9% of patients. Sinusitis after maxillary surgery is uncommon, with a reported incidence of septic complications of 0.5–4.8%. This percentage might be an undervaluation when plain films are used to evaluate the sinus. Moreover, in a number of cases, patients classified as having a complication such as excessive bleeding, loose osteosynthesis material, or non-union of the fracture, might in fact also have a sinus infection as part of the problem. Computed tomography (CT) of the paranasal sinuses is nowadays the standard for imaging of rhinosinusitis. The use of this method for sinus evaluation, however, has never been reported for the Le Fort I osteotomy.
In this pilot study, the damage to and recovery of the maxillary sinus and nasal ventilation were prospectively analysed in 20 patients. The following methods were used before and 2 months after surgery: existing validated questionnaires for sinonasal complaints (rhinosinusitis outcome measure (RSOM-31) and visual analogue scale (VAS) score), nasal endoscopy, measurement of peak nasal inspiratory flow (PNIF), and a CT scan.
The purpose of this study was to obtain insight into the perioperative condition of the maxillary sinus in the Le Fort I osteotomy. Patients might benefit from optimizing the timing of surgery and procedural improvements before, during, and after surgery.
Materials and methods
Twenty consecutive patients scheduled for a Le Fort I osteotomy were included. Patients were evaluated before surgery and at 2 months after the operation. All patients were asked to complete a RSOM-31 questionnaire, which evaluates the presence and severity of nasal, eye and ear complaints, and general, emotional, sleeping and practical problems in 31 questions. A VAS questionnaire for sinus-related complaints covering the same items in 19 questions was also completed.
A nasal endoscopy was performed using a rigid optical endoscope. In order to evaluate a possible postoperative change in nasal patency, the PNIF was measured three times in each patient using a standard air flow metre with air cushion facemask (VBM Medizintechnik GmbH, Germany), and the maximum value was scored. Preoperative and postoperative questionnaire scores and PNIF were compared by paired Student’s t -test.
A CT scan of the paranasal sinuses was done preoperatively and at 2 months after surgery to evaluate changes in sinonasal anatomy and the radiological sinus mucosa appearance of all maxillofacial sinuses. The following protocol was used (Philips Brilliance Multislice Scanner, Best, the Netherlands): axial plane 0.9 mm and increment 0.45 mm, with 1.0 mm consecutive reconstructions in the axial, coronal, and sagittal planes. The images were interpreted by a head and neck radiologist (14 years experience). Predictive Analytics SoftWare (PASW) v. 18 was used for the statistical analyses.
Results
Patients
Between 31 August 2010 and 15 March 2011, 20 consecutive patients were included. The group consisted of 12 women and eight men, with a mean age of 24.4 years (range 15–53 years), scheduled for an orthognathic procedure involving a non-segmented Le Fort I osteotomy. The indication for the operation was for functional reasons in all cases: an anterior open bite, a Class II or a Class III malocclusion. Thirteen patients underwent a bimaxillary operation and seven patients had only a Le Fort I osteotomy.
Questionnaires
Nineteen out of 20 patients returned their completed RSOM-31 questionnaire ( Table 1 ) and VAS questionnaire ( Table 2 ). There were no significant differences in the presence of sinus-related complaints before and 2 months after surgery ( P > 0.24).
| RSOM-31 item | Paired differences | |||||||
|---|---|---|---|---|---|---|---|---|
| Mean | SD | SEM | 95% CI, lower | 95% CI, upper | t | df | Significance (two-tailed) | |
| Nasal complaints | 0.079 | 1.234 | 0.283 | −0.516 | 0.674 | 0.279 | 18 | 0.784 |
| Eye complaints | 0.105 | 1.1 | 0.252 | −0.425 | 0.636 | 0.417 | 18 | 0.682 |
| Sleeping problems | 0.211 | 1.357 | 0.311 | −0.444 | 0.865 | 0.676 | 18 | 0.508 |
| Ear complaints | 0.053 | 0.78 | 0.179 | −0.323 | 0.429 | 0.294 | 18 | 0.772 |
| General complaints | 0.135 | 1.485 | 0.341 | −0.581 | 0.851 | 0.397 | 18 | 0.696 |
| Practical problems | −0.105 | 1.197 | 0.275 | −0.682 | 0.472 | −0.383 | 18 | 0.706 |
| Emotional problems | 0.053 | 1.682 | 0.386 | −0.758 | 0.864 | 0.136 | 18 | 0.893 |
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