Le Fort I osteotomy facilitated nasotracheal intubation in a patient with concha bullosa and septal deviation: a case report

Introduction: Nasotracheal intubation (NTI) is preferred for general anesthesia in maxillofacial surgery. However, NTI is often traumatic or even unsuccessful, particularly in patients with a narrow nasal pathway. In this case report, we describe a less traumatic NTI approach using maxillary downfracture of Le Fort I osteotomy.

Case presentation: A 19-year-old woman was admitted with a skeletal Class III malocclusion and scheduled to undergo bimaxillary orthognathic surgery. A preoperative evaluation revealed no other medical history and abnormal laboratory findings. Preoperative computed tomography showed nasal septal deviation, concha bullosa, and turbinate hypertrophy. A nasal Ring-Adair-Elwyn endotracheal tube and a tube exchanger could not be inserted via NTI because of her narrow nasal cavity. An oral intubation was performed temporarily and surgery was started. After a maxillary downfracture was performed, which made the nasal cavity wider than before, NTI was successfully conducted without difficulty. The patient was ventilated without any problems, and the operation was continued. Postoperatively, the patient had no further complications and her vital parameters were all stable.

Conclusions: This case report suggests that NTI after maxillary downfracture of Le Fort I osteotomy can be a good alternative that can be successfully performed with less trauma in patients undergoing orthognathic surgery who are preoperatively evaluated as having a narrow nasal cavity.

Nasotracheal intubation; Maxillary downfracture; Orthognathic surgery; Case report

[1] Prasanna D, Bhat S. Nasotracheal intubation: an overview. Journal of Maxillofacial and Oral Surgery. 2014; 13: 366–372.

[2] Ray TL, Tobias JD. An alternative technique for nasotracheal intubation. Southern Medical Journal. 2003; 96: 1039–1041.

[3] Abrons RO, Vansickle RA, Ouanes JP. Seldinger technique for nasal intubation: a case series. Journal of Clinical Anesthesia. 2016; 34: 609–611.

[4] Elwood T, Stillions DM, Woo DW, Bradford HM, Ramamoorthy C. Nasotracheal intubation: a randomized trial of two methods. Anesthesiology. 2002; 96: 51–53.

[5] Delgado AV, Sanders JC. A simple technique to reduce epistaxis and nasopharyngeal trauma during nasotracheal intubation in a child with factor IX deficiency having dental restoration. Anesthesia and Analgesia. 2004; 99: 1056–1057.

[6] Kim YC, Lee SH, Noh GJ, Cho SY, Yeom JH, Shin WJ, et al. Thermosoftening treatment of the nasotracheal tube before intubation can reduce epistaxis and nasal damage. Anesthesia and Analgesia. 2000; 91: 698–701.

[7] Katz RI, Hovagim AR, Finkelstein HS, Grinberg Y, Boccio RV, Poppers PJ. A comparison of cocaine, lidocaine with epinephrine, and oxymetazoline for prevention of epistaxis on nasotracheal intubation. Journal of Clinical Anesthesia. 1990; 2: 16–20.

[8] Hall CEJ, Shutt LE. Nasotracheal intubation for head and neck surgery. Anaesthesia. 2003; 58: 249–256.

[9] Kim Y. Complications associated with orthognathic surgery. Journal of the Korean Association of Oral and Maxillofacial Surgeons. 2017; 43: 3–15.

[10] Kim H, Yun K, Kim K, Kang H, Choi Y. Computed tomography evaluation and pretreatment for a safe nasotracheal intubation, avoiding nasal cavity injuries. Journal of the Korean Association of Oral and Maxillofacial Surgeons. 2010; 36: 197. (In Korean)

[11] Adamson DN, Theisen FC, Barrett KC. Effect of mechanical dilation on nasotracheal intubation. Journal of Oral and Maxillofacial Surgery. 1988; 46: 372–375.

[12] Buchanan EP, Hyman CH. LeFort I osteotomy. Seminars in Plastic Surgery. 2013; 27: 149–154.

[13] Movahed R, Morales-Ryan C, Allen WR, Warren S, Wolford LM. Outcome assessment of 603 cases of concomitant inferior turbinectomy and Le Fort I osteotomy. Proceedings. 2013; 26: 376–381.

[14] Song I, Choi J, Baik U, Ryu J, Lim J, Choi Y, et al. Recovery pattern following bimaxillary orthognathic surgery: Differences between sexes. Journal of Cranio-Maxillofacial Surgery. 2019; 47: 138–142.