J Oral Maxilloiac 49:1344-1345,
Surg
1990
Nasal-Vestibular Drainage Systems for Infections of the Maxilla SHELDON
M. MINT&
DDS, MS,* AND YAKIR ANAVI, DMDt
Infections of the maxilla, particularly osteomyelitis, sometimes requires irrigation and/or instillation of antibiotics. A nasal-vestibular drainage system has been designed that avoids the need for a skin incision and eliminates an intraoral exit. This system affords easy access for the establishment of maxillary drainage and irrigation. Technique Two vertical incisions are made: one in the unattached mucosa in the canine fossa and the second at the zygomaticomaxillary buttress. The incisions are made down to the bone and a subperiosteal tunnel joining them is created with a periosteal elevator. The subperiosteal tunneling is extended anteromedially along the anterior maxillary wall and, using a hemostat, the nasal vestibule is penetrated. A 0.7 x
* Clinical Professor of Oral Pathology, University of Detroit School of Dentistry; Attending Professor of Anatomy, Wayne State University School of Medicine, Detroit; Attending Oral and Maxillofacial Surgeon, Detroit Receiving Hospital; private practice, Oral and Maxillofacial Surgery, Dearborn, MI. I’ Clinical Fellow, Detroit Receiving Hospital; presently, Senior Attending Surgeon, Department of Oral and Maxillofacial Surgery, Beilinson Medical Center, Petah Tiqva, Israel. Address correspondence and reprint requests to Dr Mintz: 19855 W Outer Dr, Suite 102, Dearborn. MI 48124. 0 1990 American Association of Oral and Maxillofacial Surgeons 0278-2391/9Ol4812-0019$3.00/0
2&cm, three-fourths-perforated, flat silicone drain (Zimmer, Dover, OH) (Fig 1) is inserted through the hole in the nostril and brought through the subperiosteal tunnel. An extramucosal U-turn is then made around the distal incision, and the drain is brought forward through the anterior incision and is then advanced submucosally until it is through the nasalvestibular hole. The nonperforated segment of the drain is inserted first so that it is extramucosal, while the perforated segment lies in the subperiosteal tunnel against the maxilla (Fig 2). Watertight closure of the incisions is achieved and the perforated part of the drain is shortened to fit. Two catheter adaptors (Becton-Dickinson, Rutherford, NJ) are then attached to the lumens of the drain tubes in the nostril (Fig 3). The drain is selfretaining and no sutures are required for fixation in the nostril. A syringe is connected to the adaptor, and the system is flushed with sterile saline and the irrigating solution. The drain has been left in place up to 3 weeks with no complications. Discussion In cases where only the maxillary alveolar bone is involved by an infectious process, without an antral component, or when the overlying tissues are involved, a closed irrigation system that does not require antral invasion or skin incisions is desirable. A complete intraoral system is cumbersome to use and can be associated with discomfort due to the
FIGURE 1. The nasal-vestibular drainage system. It consists of a 0.7 x 2O-cm. three-fourths-perforated, flat sikone drain with two adaptors. Arrows denote the perforated and nonperforated segments.
1345
MINTZ AND ANAVI
anatomical constraints of the lip. To circumvent these disadvantages, a nasal-vestibular doubleportal drainage system, using a flat catheter with strategically placed perforations, has been designed. The main advantage of the method is that it can be used to drain and to irrigate the maxillary bone extraorally in serious infections and in suppurative osteomyelitis. It is technically not diffkult to place and allows easy instillation of medications and lavage by intravenous fluids. There is no morbidity, such as maceration or pressure necrosis of lips. It also affords the patient ease of ambulation, as the system is engaged or disengaged by a readily accessible nasal port. References ‘I
I
FIGURE 2. Diagram of the drain in situ. Note that the perforated part lies entirely in the subperiosteal tunnel.
FIGURE 3. A patient with maxillary osteomyelitis associated with a herpes zoster infection showing the drainage system exiting from an opening in the nostril.
1. Topazian RG, Goldberg MH: Oral and Maxillofacial Infections (ed 2). Philadelphia, Saunders, 1987, pp 204-238 2. Crockett DM, Stanley RB, Lubka R: Osteomyelitis of the maxilla in a patient with osteopetrosis (Albers-Schonberg disease). Otolaryngol Head Neck Surg 95: 117, 1986 3. Sepheriadou-Mavropoulou T, Yannoulopoulos A: Tuberculosis of the jaws. J Oral Maxillofac Surg 44:158, 1986 4. Wright WE, Davis ML, Geffen DB, et al: Aveolar bone necrosis and tooth loss: A rare complication associated with herpes zoster infection of the fifth cranial nerve. Oral Surg 56:39, 1983 5. Flynn TR. Hoekstra CW, Lawrence FR: The use of drain in oral and maxillofacial surgery: A review and a new approach. J Oral Maxillofac Surg 41:518, 1983 6. Ahmad S, Gibb AS, Gibb AG: Split cannula-Foley catheter technique in maxillary sinusitis. J Laryngol Otol 95:221. 1981 7. Bartal N, Puterman M, Grinberg L: A simple and advantageous system for continuous lavage of maxillary sinus. Laryngoscope 94:976, 1984 8. Zachariades N, Koundouris I: Maxillofacial symptoms in two patients with pyknodyostosis. J Oral Maxillofac Surg 42:819. 1984
Surg
1990
Nasal-Vestibular Drainage Systems for Infections of the Maxilla SHELDON
M. MINT&
DDS, MS,* AND YAKIR ANAVI, DMDt
Infections of the maxilla, particularly osteomyelitis, sometimes requires irrigation and/or instillation of antibiotics. A nasal-vestibular drainage system has been designed that avoids the need for a skin incision and eliminates an intraoral exit. This system affords easy access for the establishment of maxillary drainage and irrigation. Technique Two vertical incisions are made: one in the unattached mucosa in the canine fossa and the second at the zygomaticomaxillary buttress. The incisions are made down to the bone and a subperiosteal tunnel joining them is created with a periosteal elevator. The subperiosteal tunneling is extended anteromedially along the anterior maxillary wall and, using a hemostat, the nasal vestibule is penetrated. A 0.7 x
* Clinical Professor of Oral Pathology, University of Detroit School of Dentistry; Attending Professor of Anatomy, Wayne State University School of Medicine, Detroit; Attending Oral and Maxillofacial Surgeon, Detroit Receiving Hospital; private practice, Oral and Maxillofacial Surgery, Dearborn, MI. I’ Clinical Fellow, Detroit Receiving Hospital; presently, Senior Attending Surgeon, Department of Oral and Maxillofacial Surgery, Beilinson Medical Center, Petah Tiqva, Israel. Address correspondence and reprint requests to Dr Mintz: 19855 W Outer Dr, Suite 102, Dearborn. MI 48124. 0 1990 American Association of Oral and Maxillofacial Surgeons 0278-2391/9Ol4812-0019$3.00/0
2&cm, three-fourths-perforated, flat silicone drain (Zimmer, Dover, OH) (Fig 1) is inserted through the hole in the nostril and brought through the subperiosteal tunnel. An extramucosal U-turn is then made around the distal incision, and the drain is brought forward through the anterior incision and is then advanced submucosally until it is through the nasalvestibular hole. The nonperforated segment of the drain is inserted first so that it is extramucosal, while the perforated segment lies in the subperiosteal tunnel against the maxilla (Fig 2). Watertight closure of the incisions is achieved and the perforated part of the drain is shortened to fit. Two catheter adaptors (Becton-Dickinson, Rutherford, NJ) are then attached to the lumens of the drain tubes in the nostril (Fig 3). The drain is selfretaining and no sutures are required for fixation in the nostril. A syringe is connected to the adaptor, and the system is flushed with sterile saline and the irrigating solution. The drain has been left in place up to 3 weeks with no complications. Discussion In cases where only the maxillary alveolar bone is involved by an infectious process, without an antral component, or when the overlying tissues are involved, a closed irrigation system that does not require antral invasion or skin incisions is desirable. A complete intraoral system is cumbersome to use and can be associated with discomfort due to the
FIGURE 1. The nasal-vestibular drainage system. It consists of a 0.7 x 2O-cm. three-fourths-perforated, flat sikone drain with two adaptors. Arrows denote the perforated and nonperforated segments.
1345
MINTZ AND ANAVI
anatomical constraints of the lip. To circumvent these disadvantages, a nasal-vestibular doubleportal drainage system, using a flat catheter with strategically placed perforations, has been designed. The main advantage of the method is that it can be used to drain and to irrigate the maxillary bone extraorally in serious infections and in suppurative osteomyelitis. It is technically not diffkult to place and allows easy instillation of medications and lavage by intravenous fluids. There is no morbidity, such as maceration or pressure necrosis of lips. It also affords the patient ease of ambulation, as the system is engaged or disengaged by a readily accessible nasal port. References ‘I
I
FIGURE 2. Diagram of the drain in situ. Note that the perforated part lies entirely in the subperiosteal tunnel.
FIGURE 3. A patient with maxillary osteomyelitis associated with a herpes zoster infection showing the drainage system exiting from an opening in the nostril.
1. Topazian RG, Goldberg MH: Oral and Maxillofacial Infections (ed 2). Philadelphia, Saunders, 1987, pp 204-238 2. Crockett DM, Stanley RB, Lubka R: Osteomyelitis of the maxilla in a patient with osteopetrosis (Albers-Schonberg disease). Otolaryngol Head Neck Surg 95: 117, 1986 3. Sepheriadou-Mavropoulou T, Yannoulopoulos A: Tuberculosis of the jaws. J Oral Maxillofac Surg 44:158, 1986 4. Wright WE, Davis ML, Geffen DB, et al: Aveolar bone necrosis and tooth loss: A rare complication associated with herpes zoster infection of the fifth cranial nerve. Oral Surg 56:39, 1983 5. Flynn TR. Hoekstra CW, Lawrence FR: The use of drain in oral and maxillofacial surgery: A review and a new approach. J Oral Maxillofac Surg 41:518, 1983 6. Ahmad S, Gibb AS, Gibb AG: Split cannula-Foley catheter technique in maxillary sinusitis. J Laryngol Otol 95:221. 1981 7. Bartal N, Puterman M, Grinberg L: A simple and advantageous system for continuous lavage of maxillary sinus. Laryngoscope 94:976, 1984 8. Zachariades N, Koundouris I: Maxillofacial symptoms in two patients with pyknodyostosis. J Oral Maxillofac Surg 42:819. 1984
