Submental intubation versus tracheostomy in maxillofacial fractures.

OBJECTIVE: To compare submental intubation with tracheostomy in patients with maxillofacial fractures who were operated under general anesthesia and nasotracheal intubation was contraindicated. PATIENTS AND METHODS: This prospective comparative study was conducted on 32 patients undergoing maxillofacial operations. All patients had a panfacial trauma (including naso-ethmoid orbital fracture combined with mandibular fracture). Patients who had unstable cervical vertebra, laryngeal trauma, urgent tracheostomy, and patients with expected prolonged postoperative ventilation were excluded from the study. Patients were randomly assigned to elective tracheostomy and submental intubation groups. The patients were evaluated according to the time required to do elective tracheostomy or submental intubation, the operation comorbidity and complications, and the postoperative scar. RESULTS: The average time required to do submental intubation was 8.35 min versus 30.75 min required to do elective tracheostomy with significant difference (p < 0.0001). No complication was reported with submental intubation while in elective tracheostomy group, surgical emphysema was registered in two patients. The submental scar was acceptable in all patients while the tracheostomy scar needs scar revision in four cases (p = 0.0325). CONCLUSION: Submental endotracheal intubation appeared to be a simple, safe, and significantly faster reliable alternative to tracheostomy during surgical reconstruction of selected cases of maxillofacial fractures without indication for prolonged postoperative ventilation support with significantly lower morbidity.

Frontal sinus fractures with suspected outflow tract obstruction: a new approach for sinus preservation.

OBJECTIVE: The description of a new approach for the management of patients with frontal sinus fractures and associated obstruction of the frontal outflow tract to, restore sinus function and avoiding sinus obliteration. SUBJECTS AND METHODS: In a prospective study, 21 patients with anterior wall frontal sinus fractures associated with potential obstruction of the frontal outflow tract, underwent rigid internal fixation and intraoperative guarded nasal endoscopic debridement of any bony spicules and lacerated mucosa to clear the frontal recess. Patients were followed up clinically and radiologically by CT to assess the status of the frontal sinus and to detect any manifestations of frontal sinusitis or any other complications. RESULTS: Seventeen patients completed the postoperative follow-up while four patients were excluded from the study. Postoperative follow-up ranged from 6 to 34 months with a mean of 20 months. All patients had associated craniofacial fractures. Follow-up CT scans showed complete restoration of frontal sinus ventilation and mucociliary clearance for 13 patients. Four patients showed frontal sinus mild mucosal thickening without signs of chronic sinusitis. CONCLUSION: Patients with anterior wall frontal sinus fractures associated with frontal sinus outflow tract obstruction could be successfully managed with rigid internal fixation and intraoperative guarded endoscopic debridement of any bony spicules and lacerated mucosa to clear the frontal recess. This type of management could increase the chance of frontal sinus preservation and decrease the need for frontal sinus obliteration for similar patients.

Modified genioglossus advancement and uvulopalatopharyngoplasty in patients with obstructive sleep apnea.

OBJECTIVE: To describe modification of the originally described genioglossus muscle advancement and its clinical assessment in the treatment of patients with obstructive sleep apnea. STUDY DESIGN: Prospective study. SETTING: University medical hospital. SUBJECTS AND METHODS: Twenty-three patients with obstructive sleep apnea underwent modified genioglossus muscle advancement with uvulopalatopharyngoplasty. All patients were evaluated before and 6 months after surgery by history taking, clinical examination, Epworth Sleepiness Scale evaluation, fiber-optic nasopharyngoscopy, cephalometry, panoramic X-ray, and nocturnal polysomnography. RESULTS: Postoperative mean ± SD apnea-hypopnea index (AHI) decreased from 40.7 ± 17.4 to 15.4 ± 10.7 (P = .00; 95% confidence interval [CI], 18.4 to 32.27). With a success rate defined as AHI <20 and a 50% decrease in AHI of the preoperative value, the surgical success rate was 86.9%. Cephalometry analysis showed a significant difference between preoperative and postoperative findings, including a posterior airway space that increased a mean ± SD from 8.1 ± 2.5 to 12.3 ± 3.7 mm (P = .00; 95% CI, -5.89 to -3.0), position of the mandible to the cranial base (SNB degree) that increased from 77.3 ± 2.7 to 78.5 ± 1.3 (P = .005; 95% CI, -2.11 to -0.4), and improved palatal parameters. The mean (SD) average depth of the osteotomy and genioglossus advancement was 11.8 ± 2.6 mm. None of the 23 patients had mandible fracture, aesthetic changes of the chin, or detachment of the advanced genioglossus muscle. CONCLUSION: The modification described in this technique permits complete and safe capture and advancement of the whole genioglossus muscle, leading to satisfactory expansion of the retrolingual airway without stripping, detachment of the advanced genioglossus muscle, mandible fracture, or aesthetic changes of the chin.