Address for correspondence : Chan Hum Park, MD, PhD, Department of Otorhinolaryngology-Head and Neck Surgery, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, 77 Sakju-ro, Chuncheon 200-704, Korea
Tel : +82-33-240-5181, Fax : +82-33-241-2909, E-mail : hlpch@paran.com

INTRODUCTION

The maxillary sinus is frequently involved in facial bone fracture,¹⁾ because the maxilla is closely connected to other facial bones and it is composed of only a thin bony wall. Early detection, accurate recognition of maxillary trauma as well as its treatment are important, because it directly affects facial contour. Conventional treatment of maxillary fractures has been open reduction with plate fixation. Although the maxillary anterior wall is relatively easy to access, the problems following conventional treatment, such as incision lines, insertion of drainage tubes, postoperative pain, relatively high costs and lengthy operation times can be burdens to patients.
Ultrasonography has been studied for the diagnosis and treatment for facial bone fractures.²⁾ As an accurate, safe, portable, and real-time imaging modality, it has many advantages. Therefore, some authors have considered the use of ultrasonography during the intraoperative period.³⁾
Various surgical approaches other than the conventional open reduction technique have been used to treat inferior orbital wall fractures, instead of open reduction. One of these, an endoscopic approach to inferior orbital wall through the maxillary natural ostium and Foley catheter inflation in the maxillary sinus, provides a safe and less invasive treatment.⁴⁾ The authors report a case of an anterior maxillary fracture successfully treated by applying the endoscopic approach method with a Foley catheter and real-time ultrasonography.

Case

A 24-year-old man presented with right buccal pain for three days after an unintentional trauma caused by his friend. The patient denied any medical history, including chronic rhinosinusitis, allergic rhinitis, sinonasal or dental surgery. Examination of the nasal cavity showed unremarkable findings, except for right-side inferior turbinate hypertrophy. However, examination of the right side of his face revealed the cheek tenderness. Consequently, axial computed tomography (CT) of facial bones revealed the right anterior maxillary wall fracture with up to a 4 mm depression, compared to the left side (Fig. 1).
An endoscopic balloon reduction was performed under general anesthesia. The surgery began with a right side middle meatal antrostomy (MMA), as used in endoscopic sinus surgery. After the MMA, a 16-Fr Foley catheter was inserted through the widened natural ostium of the maxillary sinus (Fig. 2). A 30-40 mL injection of normal saline, injected into the Foley catheter under endoscopic guidance, inflated the balloon. Ultrasonography (z.one, Zonare Medical System, Mountain View, CA, USA) with a broadband linear array transducer (L 10-5, Zonare Medical System, CA, USA)(Fig. 3) was used to monitor the repositioning process. The frequency was set at 10 MHz, depending on the image quality required. Using realtime ultrasonographic images, bony fragments were repositioned (Fig. 4). After the procedure, the Foley catheter was removed. Intranasal packing material was inserted, and an external splint was applied to protect the anterior maxillary wall. Postoperative CT images, checked one day after the operation, showed the depression markedly elevated. Intranasal packing material was removed two days later and the patient was discharged from the hospital without any complications at that time. Three months later, the patient had a good appearance with no evidence of complications or deformities.

Discussion

Maxilla and other adjoining facial bones are important components of facial contour because of its location. Among them, the maxillary anterior wall consists of thin bone because of low loading during normal function; load transmission occurs through the perinasal and zygomatic buttress. Therefore, the anterior maxillary wall is most frequently involved in fractures due to the trauma by assaults, sports injuries, or traffic accidents.⁵⁾ Currently, the aim of surgical treat-ment in maxillary anterior wall fractures is not only successful reduction of bone fragments but also patient satisfaction in perioperative and postoperative periods. The endoscopic guided Foley catheter inflation technique, as used in inferior orbital wall fracture reduction, achieved these goals. In the present case, the fracture was localized to the anterior wall of the maxilla, providing the best candidacy for a minimally invasive operation. Moreover, ultrasonography permitted direct visualization of the anterior wall reduction.
Use of ultrasonography in facial bone region was first introduced in 1990.⁶⁾ Many studies have reported high sensitivity and specificity of ultrasound in facial bone fracture.⁷⁾ These results confirmed ultrasonography to be a useful visualizing tool for facial bone fractures, regardless of the type of displacement.⁸⁾ After the first study showed its advantages in intraoperative periods,⁶⁾ the authors' facility showed its usefulness in closed reduction of nasal bone and zygoma.^9,10) Ultrasonography is easy, noninvasive, and quick to perform, and intraoperative usage of ultrasonography enables more accurate reductions. Cases such as the one presented here, where the operation uses an indirect approach, show optimal indications for ultrasonography.
This operation technique has many advantages. First, this treatment has the advantage of reduced operation time. Expert surgeons need only few minutes to insert the Foley catheter in the maxillary sinus. Swift operations help patients to recover quickly and also prevent rising hospital fees. Second, the treatment does not needed complex operation tools, such as drills, screw and plate; consequently, it avoids the potential risk of plate-related problems associated with plate fixation surgery. Recently developed absorbable plates might lower the complications, but one study reported that over 20% of patients with plate fixation had plate removal due to its complications, such as facial discomfort, exposure, cold intolerance and infection.¹¹⁾ Third, because this technique does not need a skin incision, there are fewer possibilities of wound infection and postoperative discomfort. In a study where the basic fracture treatment was open reduction and internal fixation, only 40% were free of complaints, where in the remaining 60%, there were 66% of the patients with complaints who were required to use medication.¹²⁾ As for our patient, there was no need for additional painkillers except the routinely given acetaminophen tablets for one day after surgery.
Even though there are many advantages of endoscopic approach, there are still issues to consider. In cases of complex maxillary fractures or combined fractures with other facial bones, insufficient correction may be at risk; for these cases, conventional open reduction might be a better treatment option. In general, a minimal anterior maxillary fracture, as in this case, there is no need for correction. However, the authors encountered patients who complained of subtle facial changes after trauma. These patients were satisfied with the results after surgery. Therefore, active management is occasionally required in fractures of anterior maxillary wall. Paying attention to the eye is also desirable. Of the entire maxillary sinus wall, the superior maxillary wall is well known for its thin osseous components. Consequently, the authors paid special attention to the patient's eye during the operation. The surgeon intermittently checked the orbital pressure by palpation on the eyelid and the pupil light reflex. During the postoperative period, the patient had no complaints regarding his eyes.
Also, there were some unexpected situations with this technique in our experience. In some cases, a Foley catheter was completely twisted in the sinus due to its high pressure when the assistant pushed normal saline, and the handle of the syringe was unable to be moved. However, the authors solved this problem by simply rupturing the Foley balloon with a sharp spinal needle.
In conclusion, the authors recommend the endoscopy-guided Foley catheter inflation technique with real-time ultrasonography as an alternative technique to open reduction in maxillary anterior wall fractures, which based on the limited experience of this study, highlighted its effectiveness and its numerous advantages.

1. Jung HW, Min YG, Lee CH. A clinical study of facial bone fractures. Korean J Otolaryngol-Head Neck Surg 1990;33(4):787-93.

2. Blessmann M, Pohlenz P, Blake FA, Lenard M, Schmelzle R, Heiland M. Validation of a new training tool for ultrasound as a diagnostic modality in suspected midfacial fractures. Int J Oral Maxillofac Surg 2007;36(6):501-6.

3. Friedrich RE, Volkenstein RJ. [The value of ultrasonography in the diagnosis of zygomatic arch fractures]. Dtsch Z Mund Kiefer Gesichtschir 1991;15(6):472-9.

4. Ikeda K, Suzuki H, Oshima T, Takasaka T. Endoscopic endonasal repair of orbital floor fracture. Arch Otolaryngol Head Neck Surg 1999;125(1):59-63.

5. Majewski WT, Yu JC, Ewart C, Aguillon A. Posttraumatic craniofacial reconstruction using combined resorbable and nonresorbable fixation systems. Ann Plast Surg 2002;48(5):471-6.

6. Akizuki H, Yoshida H, Michi K. Ultrasonographic evaluation during reduction of zygomatic arch fractures. J Craniomaxillofac Surg 1990;18(6):263-6.

7. Adeyemo WL, Akadiri OA. A systematic review of the diagnostic role of ultrasonography in maxillofacial fractures. Int J Oral Maxillofac Surg 2011;40(7):655-61.

8. Hong HS, Cha JG, Paik SH, Park SJ, Park JS, Kim DH, et al. High-resolution sonography for nasal fracture in children. AJR Am J Roentgenol 2007;188(1):W86-92.

9. Park CH, Joung HH, Lee JH, Hong SM. Usefulness of ultrasonography in the treatment of nasal bone fractures. J Trauma 2009;67(6):1323-6.

10. Park CH, Hong SJ, Lee JH, Yang SM, Kwon TK, Joung HH. The usefullness of ultrasonography in the treatment of zygomatic arch fractures. Korean J Otolaryngol-Head Neck Surg 2007;50(7):608-11.

11. Nagase DY, Courtemanche DJ, Peters DA. Plate removal in traumatic facial fractures: 13-year practice review. Ann Plast Surg. 2005;55(6):608-11.

12. Top H, Aygit C, Sarikaya A, Karaman D, Firat MF. Evaluation of maxillary sinus after treatment of midfacial fractures. J Oral Maxillofac Surg 2004;62(10):1229-36.