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Unusual case of chronic maxillary rhinosinusitis.

A 32-year-old woman presented with a 3-month history of rhinosinusitis, especially causing right-sided maxillary discomfort. Her medical history included placement of a maxillary transpalatal distractor (TPD) for a class III dentoskeletal maxillomandibular dysmorphism with mandibular hyperdivergence 7 months earlier. At that time, postoperative radiography had showed correct positioning of the device (figure 1). The TPD needed to be removed 6 months after osteosynthesis, but the patient had not shown up at the postoperative consultation. She lost the right screw of the device several weeks before the appearance of the sinonasal symptoms.

Flexible rhinoendoscopy revealed purulent secretions in the right middle meatus, suggesting right unilateral rhinosinusitis. Computed tomography confirmed this diagnosis and showed migration of the right lateral portion of the TPD in the right maxillary sinus floor (figure 2). The maxillofacial and ENT surgeons proposed to remove the device, close the orosinusal communication, and perform functional endoscopic sinus surgery. However, the patient refused the intervention.

Most patients with class III dental occlusion and maxillary hypoplasia require maxillary advancement that can be accomplished by maxillary distraction. This procedure consists of Le Fort osteotomy and fixation of a distraction device. After the intervention, the maxillary bone is progressively distracted to achieve class I dental occlusion. Compared to conventional orthognathic surgery, this technique provides better results in terms of maxilla movement and risk of recurrence. (1) However, postoperative complications are not well documented and are mostly reported for maxillary distraction in cleft lip and palate subjects. (2,3)

Complications include device dysfunction, distractor failures during the consolidation period, significant pain during activation, ophthalmic complications, and difficulties associated with the permucosal entry side (mucosal ulcerations, palatal abscess, and oronasal fistula). (3)

Chronic maxillary rhinosinusitis, the most common ENT pathology in the United States, (4) as seen in the present case, could be another complication. It can be caused by iatrogenic etiology, which is found in 5 to 40% of cases. (5) Although maxillary rhinosinusitis due to migration of a distractor is rare, it must be suspected in all patients with a history of dysmorphism surgery and unilateral rhinosinusitis.

Jerome R. Lechien, MD, MSc; Julien W. Hsieh, MD; Sven Saussez, MD, PhD

From the Laboratory of Anatomy and Cell Biology, Faculty of Medicine, Research Institute for Health Sciences and Technology, University of Mons, Mons, Belgium (Dr. Lechien and Dr. Saussez); the Laboratory of Neurogenetics and Behavior, The Rockefeller University, New York City (Dr. Hsieh); and the Department of Otolaryngology, Head and Neck Surgery, CHU Saint-Pierre, Faculty of Medicine, Universite Libre de Bruxelles, Brussels, Belgium (Dr. Saussez).

References

(1.) Rachmiel A, Even-Almos M, Aizenbud D. Treatment of maxillary deft palate: Distraction osteogenesis vs. orthognathic surgery. Ann Maxillofac Surg 2012;2(2):127-30.

(2.) Jeblaoui Y, Morand B, Brix M, et al. Maxillary distraction complications in cleft patients. Rev Stomatol Chir Maxillofac 2010;lll(3):el-6.

(3.) Verstraaten f, Kuijpers-Jagtman AM, Mommaerts MY, et al. Eurocran Distraction Osteogenesis Group. A systematic review of the effects of bone-borne surgical assisted rapid maxillary expansion. J Craniomaxillofac Surg 2010;38(3):166-74.

(4.) Chee L, Graham SM, Carothers DG, Bailas ZK. Immune dysfunction in refractory sinusitis in a tertiary care setting. Laryngoscope 2001 ; 111(2):233-5.

(5.) Lechien JR, Filleul O, Costa de Araujo P, et al. Chronic maxillary rhinosinusitis of dental origin: A systematic review of 674 patient cases. Int J Otolaryngol 2014;2014:465173. doi: 10.1155/2014/465173. Epub 2014 Apr 8.

Caption: Figure 1. Postoperative radiography shows the correct positioning of the TPD.

Caption: Figure 2. Computed tomography performed 7 months after surgery reveals the unilateral chronic maxillary rhinosinusitis caused by TPD protrusion through the right maxillary sinus floor.
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Title Annotation:IMAGING CLINIC
Author:Lechien, Jerome R.; Hsieh, Julien W.; Sauces, Sven
Publication:Ear, Nose and Throat Journal
Article Type:Case study
Date:Mar 1, 2017
Words:603
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