腭裂患儿咽鼓管功能障碍与中耳疾病的研究

目的 :探讨不同年龄组腭裂患儿咽鼓管功能障碍与中耳疾病的发病情况。方法 :对 121例腭裂患儿 ,242耳 ,分为早期腭帆修复组 (手术时平均年龄为 3 2个月 )与延迟腭帆修复组 (手术时平均年龄为 15个月 ) ,在术前、术后 1年进行耳镜 ,耳显微镜检查和鼓膜穿刺术或鼓膜切开术。结果 :两组患儿均有 90 %以上的中耳有病理性渗出 ,但延迟手术组患儿的中耳渗出向粘稠化 ,感染化转变 ,两组患儿中耳渗出情况在术后 1年明显好转。结论 :腭裂患儿应尽早作耳科相关检查 ,对病理性渗出的中耳 ,应置放鼓室平衡管 ,以消除负压和引流 ,早期的腭帆修复术对咽鼓管及中耳功能的恢复有明显的改善。     

The role of the tensor veli palatini muscle in the development of cleft palate-associated middle ear problems

Objective

Otitis media with effusion is common in infants with an unrepaired cleft palate. Although its prevalence is reduced after cleft surgery, many children continue to suffer from middle ear problems during childhood. While the tensor veli palatini muscle is thought to be involved in middle ear ventilation, evidence about its exact anatomy, function, and role in cleft palate surgery is limited.This study aimed to perform a thorough review of the literature on (1) the role of the tensor veli palatini muscle in the Eustachian tube opening and middle ear ventilation, (2) anatomical anomalies in cleft palate infants related to middle ear disease, and (3) their implications for surgical techniques used in cleft palate repair.

Materials and methods

A literature search on the MEDLINE database was performed using a combination of the keywords “tensor veli palatini muscle,” “Eustachian tube,” “otitis media with effusion,” and “cleft palate.”

Results

Several studies confirm the important role of the tensor veli palatini muscle in the Eustachian tube opening mechanism. Maintaining the integrity of the tensor veli palatini muscle during cleft palate surgery seems to improve long-term otological outcome. However, anatomical variations in cleft palate children may alter the effect of the tensor veli palatini muscle on the Eustachian tube’s dilatation mechanism.

Conclusion

More research is warranted to clarify the role of the tensor veli palatini muscle in cleft palate-associated Eustachian tube dysfunction and development of middle ear problems.

Clinical relevance

Optimized surgical management of cleft palate could potentially reduce associated middle ear problems.

     

腭裂患者中耳功能障碍及治疗

目的 探讨腭裂患者中耳功能障碍与腭裂修复术及术前年龄的关系,了解腭裂患者分泌性中耳炎鼓室分泌物细胞培养的情况及鼓室置管治疗的初步效果。方法 采用声导检查和纯音测听判断中耳功能及听力,鼓室分泌细菌培养,了解分泌性中耳炎分泌物特点,结果 腭裂术前患者７５．５％为异常鼓室图,其中３岁前患者高达８１％,术后患者４１．２％为异常鼓室图,鼓室分泌物细菌培养,革兰氏阳性和阴性菌阳性率分别为２０．１％和２４％。６     

An alternative treatment approach for patients with resistant otitis media with effusion and dysfunctional Eustachian tube:: A pilot study with rapid maxillary expansion

ObjectivesTo determine whether dysfunctional Eustachian tubes of children with resistant otitis media with effusion (OME), ventilation tube placement indication, and maxillary constriction will recover after rapid maxillary expansion (RME).Materials and MethodsThe RME group consisted of 15 children (mean age: 10.07 years) with maxillary constriction, Eustachian tube dysfunction (ETD), and resistant OME. The control group consisted of 11 healthy children (mean age: 8.34 years) with no orthodontic and/or rhinologic problems. Recovery of Eustachian tube dysfunction was evaluated by Williams'' test at three timepoints: before RME/at baseline (T0); after RME (T1); and after an observation period of 10 months (T2). The control group was matched to all these periods, except T1.ResultsIn the control group, functioning Eustachian tubes were observed in all ears at baseline (T0), and tubes showed no worsening and no change during the observation period (T2) (P > .05). In the RME group, functioning Eustachian tubes were observed in eight of 30 ears and ETD was observed in the remaining 22 ears at baseline (T0). The RME group showed significant improvements in tube functions after RME and the observation period (P < .05). Fifteen of 22 dysfunctional ears recovered (68.2%) and started to exhibit normal Eustachian tube function after RME (T1) and the observation period (T2).ConclusionsThe findings suggest that ears having poorly functioning Eustachian tubes are restored and recovered after RME in most of children with maxillary constriction and resistant OME. Thus, RME should be preferred as a first therapy alternative for children with maxillary constriction and serous otitis media.     

Relevance of the pharyngotympanic tube.

The auditory (Eustachian) tube connects the middle ear with the nasopharynx. This conduit permits equalisation of pressure between the middle ear and the throat. Balanced pressure allows the eardrum to vibrate freely as sound waves strike it. The auditory tube is also a potential anatomical route whereby opportunistic pathogens may migrate from the nose and throat to the middle ear. Eustachian tube (ET) function is disturbed in children with cleft palate, thereby rendering them susceptible to chronic otitis media with effusion (OME) and temporary conductive deafness. ET obstruction follows in these patients, and is thought to be related to the inability of the tensor veli palatini (TVP) to function properly. This anatomical overview reviews the clinical importance of the ET in the normal population and children with cleft palate.     

腭裂修复术同期鼓室置管的疗效及并发症防治

目的　探讨腭裂伴渗出性中耳炎患儿的联合治疗。方法　比较38例(49侧耳)单纯性腭裂修复术与24 例(39侧耳)腭裂修复同期行鼓膜切开、PE管置入术对中耳积液的消除及听力的影响,并对置管术的适应证、操作要点、并发症的防治进行讨论。结果　腭裂修复同期鼓膜切开置管组术后6月48·7%的患耳中耳积液消失,明显高于单纯腭裂修复组。听力损害的患儿置管后听力平均提高17 dB。结论　有中耳积液的腭裂患儿在腭裂修复术同期行鼓室切开、PE管置入术,有助于改善患儿的中耳功能。     

Tensor veli palatini muscle tension sling for eustachian tube function in cleft palate. Surgical technique and audiometric examination

The high incidence of middle ear effusion in cleft lip and/or palate infants and children led to the development of a tension sling for the tensor veli palatini muscle for better Eustachian tube function after intravelar veloplasty.--The surgical technique is outlined in this paper and an audiometric examination was conducted to determine the influence of this surgical modification, performed in the same procedure as the intravelar veloplasty, on the Eustachian tube function. The intra- and intergroup comparisons indicate that this surgical technique has a positive influence on the tube function.     

Auditory changes in patients undergoing orthognathic surgery

During orthognathic surgery, especially on the maxilla, osteotomies and displacements cause paratubular muscle dysfunction due to edema and muscle traction. This can cause auditory dysfunction. The aim of this study was to determine the effects of orthognathic surgery on the auditory status of patients. 54 consecutive patients who met the inclusion criteria underwent audiometric tests 24 h preoperatively, and 48 h 6 weeks and 8 weeks postoperatively (2 weeks after maxillomandibular fixation removal). Surgery was on the maxilla, mandible or both. The types of movements were recorded. Audiometric examinations included pure tone audiometry, tympanometry and Eustachian tube function test. In the maxillary and bimaxillary procedures, there was some auditory system dysfunction (p < 0.05). At the end of the study, a few patients had some mild dysfunction (p < 0/05). In conclusion, orthognathic surgery (mainly maxillary and bimaxillary procedures) can cause some auditory system dysfunction, which is mild and transient in most cases and requires no intervention.     

Temporomandibular disorders and orthognathic surgery

The relations between temporomandibular dysfunctions (TMDs) and maxillomandibular malformations requiring orthognathic surgery for correction have been the object of different studies in medical literature. The authors have performed a bibliographic revision on this issue to show the state of the art. This study, an analysis of the literature of the last 20 years, is chronologically presented. It analyzes the prevalence of TMD in patients with different types of maxillomandibular deformities undergoing orthognathic surgery and the TMD changes that occurred after an orthognathic surgical treatment. Medical studies reported in literature show a high variation of results related both to the prevalence of TMD in patients with maxillomandibular deformities and to the changes ensuing from an orthognathic surgical treatment. It has been difficult to compare the different studies because of the different methods used to individuate TMD signs and symptoms in the groups of patients analyzed, as well as the different types of orthognathic surgery performed and the specific TMD treatments used when required. It is concluded that despite the different results provided by the various studies, a certain prevalence of TMD is always present in patients with maxillomandibular deformity. This can be assumed to be within a correlation between dysgnathia and TMDs, and it asserts the necessity to treat patients who have maxillomandibular deformities and TMD by performing a specific treatment of TMD.     

Effect of palatoplasty on the function of the Eustachian tube in children with cleft palate

Eustachian tube function of 24 children with cleft palate (37 ears) was evaluated longitudinally utilizing the inflation-deflation and forced-response tests before and after palatoplasty. Our results for children in this longitudinal study showed that the passive function of the tube was improved following palatoplasty. Active tubal function, which measures the muscle-induced tubal dilations, was little affected by the procedure. The majority of ears tested both before and after palatoplasty demonstrated tubal dilations with swallowing. In contrast, cross-sectional data conducted on the children with a history of otitis media and repaired cleft palates, documented a severe defect in this active tubal function with 70 percent of the tests evidencing a tubal constriction. These data suggest that the results of Eustachian tube function tests may be prognostic of the future course of ear disease in these children.     

腭裂伴发中耳炎的诊治要点

腭裂伴发中耳炎的诊治是唇腭裂序列治疗中的重要组成部分,四川大学华西口腔医院唇腭裂外科较早地在国内开展了腭裂伴发中耳炎的诊断和治疗研究。本文对腭裂伴发中耳炎的高发性、隐匿性和潜在危害性进行介绍,并提出了早期积极治疗是腭裂伴发中耳炎的基本治疗原则,总结了鼓膜切开置管术的适应证、手术时机及技术要点等。     

正颌术后罕见并发症—气胸合并肺部感染1例报告

本文报告1例罕见的正颌术后发生气胸合并肺部感染病例。在双颌手术(上颌Le Fort I型截骨术,下颌BSSRO术,颏成形术)术后第3天,患者出现右肺上部气胸合并右肺内下部感染症状。在行胸腔闭式引流、低流量吸氧以及相应的支持治疗后,右肺气胸积气明显减少,肺部炎症逐渐吸收。术后3个月复查,患者完全康复。复习文献,未发现正颌术后气胸合并肺炎的其他报告。     

Descending necrotizing mediastinitis and facial palsy as serial complications in orthognathic surgery

Orthognathic surgery is one of the most commonly performed cosmetic surgical procedures. Hemorrhage, infection, and facial palsy have been reported as complications of the surgery, but the occurrence is low. Our patient presented with facial palsy, postoperative bleeding, wound dehiscence, and descending necrotizing mediastinitis in a sequence. This is the first report of descending necrotizing mediastinitis after orthognathic surgery. Although these are very rare complications, awareness of the clinical presentation and the management of these conditions are important.     

Conservative management of otitis media in cleft palate.

AIMS: Eustachian tube dysfunction affects nearly all children with cleft palate but its management is controversial. Some units perform routine prophylactic grommet insertion at the time of palate repair, whilst others are more conservative, inserting grommets only when signs and symptoms of otitis media with effusion are present. This study aims to present outcome data from one cleft team practising a conservative approach. DESIGN: This is a retrospective study in which consecutive palate repairs over 10 years are analysed and compared with previously published data. The spectrum of clefting and severity (LAHSHAL), otological and speech outcomes were recorded. Patients were excluded if incomplete data was available, and if sensorineural deafness or syndromic clefting was present. RESULTS: Data is presented for 72 of 109 consecutive patients and the 37 excluded patients are discussed. Following a conservative approach to otitis media with effusion, 29% of cases required grommets. The use of grommets seemed to be more common in those with more severe clefting. Despite this, the group receiving grommets had better speech results than those who did not, although this improvement was not statistically significant. CONCLUSIONS: There is no evidence of poor overall otological outcome in this series. The data demonstrates that those receiving grommets had better results despite more severe clefting.     

Bilateral benign paroxysmal positional vertigo: an unusual complication of orthognathic surgery

Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo of labyrinthine origin and usually idiopathic. However, 15–20% of all cases occur after trauma to the head, and it has rarely been reported after maxillofacial surgery, so to the best of our knowledge this is the first report of its bilateral occurrence after orthognathic surgery. It resolves slowly, but symptoms are incapacitating. It can be diagnosed from the history and physical examination, including the Dix–Hallpike test. Maxillofacial surgeons should be aware of it in patients who complain of dizziness after orthognathic surgery, and should know how to manage it properly.     

Prevalence of nasolacrimal canal obstruction and epiphora following maxillary orthognathic surgery

Acquired injuries of the nasolacrimal apparatus may be the result of craniomaxillofacial surgical procedures, facial trauma, or inflammation. Injury to the nasolacrimal duct system following maxillary orthognathic surgery is rarely reported. This study evaluated the importance of early diagnosis and treatment of epiphora developing after Le Fort I surgery. The records of 83 patients who underwent maxillary orthognathic surgery over a 2-year period were reviewed. The prevalence of postoperative epiphora was 3.6% and it persisted for a mean of 32.7 days. No patient required further surgical treatment of the nasolacrimal duct obstruction. Clinicians should evaluate the lacrimal canal position and schedule close postoperative follow-up of injuries to the nasolacrimal apparatus. These may become permanent, necessitating additional surgery.     

Severe bleeding from a duodenal ulcer after orthognathic surgery: a case report

Chronic non-steroidal anti-inflammatory drug use is strongly associated with peptic ulcer disease, and corticosteroid use has also been cited as a risk factor. Both are frequently prescribed for short courses after orthognathic surgery to minimize edema. It appears that no cases of severe bleeding from a duodenal ulcer have been reported during the postoperative period after orthognathic surgery. This case describes a patient who experienced this severe bleeding despite having no risk factors.     

Pseudoaneurysm of the facial artery occurred after mandibular sagittal split ramus osteotomy

Introduction

Pseudoaneurysms are caused by rupture of arteries with extravasation of blood. The compressed perivascular tissue forms the wall of aneurysmal sac. Pseudoaneurysm directly related with surgical procedure of sagittal split ramus osteotomy (SSRO) was reported quite rarely especially related with facial artery during the vertical osteotomy.

Case report

SSRO was carried out for a 19-year-old male; the patient visited the emergency room with notable swelling 3 weeks after the surgery. We experienced severe intra-oral bleeding with surgical exploration. Angiography revealed a pseudoaneurysm of the right facial artery that might be related with vertical osteotomy over lateral cortex of the mandibular body during orthognathic surgery. This implies that the minor vascular trauma from vertical osteotomy of the mandibular body during the conventional orthognathic surgery might cause later development of pseudoaneurysm.     

Orthognathic surgery of a patient with oligodontia: alternative technique for intermaxillary fixation

ABSTRACT: Oligodontia may cause various problems during orthognathic surgery because it may be difficult to fix the surgical guide splints. The aim of this clinical report was to present an alternative technique for intermaxillary fixation of a patient with oligodontia and facial deformity. A 20-year-old male patient, whose 8 maxillary and 11 mandibular teeth were congenitally missing, was treated using bimaxillary orthognathic surgery. Before the surgical approach, fixed mandibular prosthesis containing pins on the vestibule sides of the crowns was constructed to provide anchorage for intermaxillary splint and to achieve occlusal stability and vertical dimension during the surgery. This prosthesis was also used to hang intraoral elastics during the postoperative orthodontic treatment. At the end of treatment, these pins were cut, composite restoration material was applied to camouflage the places of the pins, and the patient continued to use this prosthesis. The patient gained an appropriate facial aesthetics and oral function using multidisciplinary approach.     

Orthognathic surgical planning on three-dimensional stereolithographic biomodel

The aim of this report was to present the orthognathic surgical planning of a patient with maxillary retrusion, mandibular prognathism, and midline shift on a three-dimensional stereolithographic biomodel. A patient who complained about facial deformity and difficulty in chewing was referred to our department. After a short-term presurgical orthodontic treatment, Le Fort I osteotomy and bilateral sagittal split ramus osteotomy were performed. Triangular axial gaps occurred anteriorly and posteriorly between the proximal and distal segments of the osteotomized mandible. These gaps were filled with bone grafts in accordance with templates that were constructed on a three-dimensional stereolithographic biomodel. Rotational movement of the distal mandibular segment around the y axis caused axial triangular gapping between the proximal and distal mandibular segments. In the presented case, orthognathic surgical planning was performed on the three-dimensional solid models, and templates were reconstructed according to these gaps. These templates were used to determine the size of the bone grafts during the surgical approach. The patient was diagnosed with lateral cephalometric and posteroanterior cephalometric analysis in postretention for 2 years, and it was determined that long-term results were perfect and skeletal relapse did not occur after 2.5 years of surgery. Movement at the site of the osteotomy is usually the main cause of relapse after orthognathic surgery. In the presented case, a three-dimensional stereolithographic biomodel was used to plan the orthognathic surgery and to reconstruct the templates to determine the size and shape of the bone grafts. Using bone grafts established close contact between proximal and distal osteotomized bone segments, enhanced bone healing, and diminished relapse risk.